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General NPI Number Information
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NPI Number | 1073915245
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Entity Type | Organization
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Legal Business Name | TEXAS RADIATION ONCOLOGY MEDICAL GROUP, PLLC
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Dates
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Enumeration Date | 09/19/2014
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Last Update Date | 01/09/2015
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Provider Practice Location Address
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Address Line | 2800 STATE HWY 114 EAST SUITE 100
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City | TROPHY CLUB
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State | TX
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Zip | 76262
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Country | US
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Telephone | 817-693-0900
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Fax |
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Provider Business Mailing Address
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Address Line | 2865 E COAST HWY 200
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City | CORONA DEL MAR
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State | CA
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Zip | 92625-2236
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Country | US
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Telephone | 949-385-5012
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Fax |
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Authorized Official
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Title or Position | MEDICAL DOCTOR
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Name | DR. AJMEL A PUTHAWALA
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Credential | MD
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Telephone | 714-962-1700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0001X
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Taxonomy Name | Radiation Oncology Physician
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License Number |
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License Number State |
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