Healthcare Provider Details

I. General information

NPI: 1558719682
Provider Name (Legal Business Name): NORTH DALLAS EPILEPSY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2016
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4716 RAVENDALE DR
RICHARDSON TX
75082-3835
US

IV. Provider business mailing address

4716 RAVENDALE DR
RICHARDSON TX
75082-3835
US

V. Phone/Fax

Practice location:
  • Phone: 972-860-9024
  • Fax: 972-525-8845
Mailing address:
  • Phone: 972-860-9024
  • Fax: 972-525-8845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberM7461
License Number StateTX

VIII. Authorized Official

Name: VENKATESH NAGARADDI
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 972-860-9024