Healthcare Provider Details

I. General information

NPI: 1477765113
Provider Name (Legal Business Name): NANDINI CHANNABASAPPA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 04/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 MEDICAL DISTRICT DR
DALLAS TX
75235-7701
US

IV. Provider business mailing address

PO BOX 845347
DALLAS TX
75284-5347
US

V. Phone/Fax

Practice location:
  • Phone: 214-456-8000
  • Fax: 214-456-8006
Mailing address:
  • Phone: 214-456-8000
  • Fax: 214-456-8006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM7903
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberM7903
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: