Healthcare Provider Details

I. General information

NPI: 1902199185
Provider Name (Legal Business Name): PREETAM GONGIDI D.O., M.H.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2011
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 PENNSYLVANIA AVE
FORT WORTH TX
76104-2224
US

IV. Provider business mailing address

816 W CANNON ST
FORT WORTH TX
76104-3146
US

V. Phone/Fax

Practice location:
  • Phone: 817-321-0300
  • Fax:
Mailing address:
  • Phone: 817-321-0937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberOT016084
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number34798
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number345512
License Number StateLA
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberR3089
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: