Healthcare Provider Details

I. General information

NPI: 1417128505
Provider Name (Legal Business Name): DALLAS INSTITUTE OF ADVANCED MEDICINE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 10/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2909 S HAMPTON RD SUITE F- 122, LOCK BOX 29
DALLAS TX
75224-3000
US

IV. Provider business mailing address

DALLAS INSTITUTE OF ADVANCED MEDICINE INC6 P.O. BOX 9236
DALLAS TX
75209-9236
US

V. Phone/Fax

Practice location:
  • Phone: 214-339-9350
  • Fax: 214-331-9164
Mailing address:
  • Phone: 214-339-9350
  • Fax: 214-331-9164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberJ1085
License Number StateTX

VIII. Authorized Official

Name: DR. EDWIN ESCOBAR-VAZQUEZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 214-339-9350