=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114355385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT GASTROENTEROLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2013
-----------------------------------------------------
Last Update Date | 05/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 REGENCY PKWY STE 101
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-5165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-400-2153
-----------------------------------------------------
Fax | 972-572-2228
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 309 REGENCY PKWY STE 101
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-5165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-400-2153
-----------------------------------------------------
Fax | 972-572-2228
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SUNITHA PUDHOTA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 682-400-2153
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | P1484
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------