=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063781334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST TEXAS IMAGING CENTER PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2011
-----------------------------------------------------
Last Update Date | 04/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 N MUSKINGUM AVE
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79761-5152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-335-8400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 320 N MUSKINGUM AVE
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79761-5152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-335-8400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | DR. SAJJADUL ISLAM
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 432-335-8400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | G7240
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------