Healthcare Provider Details

I. General information

NPI: 1043411531
Provider Name (Legal Business Name): SURESH N. GADASALLI,M.D.,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2651 KERMIT HWY
ODESSA TX
79763-2542
US

IV. Provider business mailing address

PO BOX 362
ODESSA TX
79760-0362
US

V. Phone/Fax

Practice location:
  • Phone: 432-333-3637
  • Fax:
Mailing address:
  • Phone: 432-580-5891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: SOWJANYA SUDESH
Title or Position: ADMINISTRATOR
Credential:
Phone: 432-580-5891