Healthcare Provider Details

I. General information

NPI: 1619006228
Provider Name (Legal Business Name): VASANTHA AGUSALA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 N ALLEGHANEY AVE SUITE 402
ODESSA TX
79761-5052
US

IV. Provider business mailing address

318 N ALLEGHANEY AVE SUITE 402
ODESSA TX
79761-5052
US

V. Phone/Fax

Practice location:
  • Phone: 432-337-2714
  • Fax: 432-337-2726
Mailing address:
  • Phone: 432-337-2714
  • Fax: 432-337-2726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberK3962
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: