Healthcare Provider Details

I. General information

NPI: 1306555347
Provider Name (Legal Business Name): CAMESHA DANDIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2022
Last Update Date: 11/18/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 W PRESIDENT GEORGE BUSH HWY STE 200
RICHARDSON TX
75080-1137
US

IV. Provider business mailing address

3133 MORGAN MEADOW LN
PEARLAND TX
77584-3281
US

V. Phone/Fax

Practice location:
  • Phone: 800-328-5979
  • Fax:
Mailing address:
  • Phone: 201-535-8686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number1065795
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number1065795
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: