=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124212162
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LALITHA JAGADISH, M.D., P.A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2007
-----------------------------------------------------
Last Update Date | 10/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11803 SOUTH FWY SUITE 201
-----------------------------------------------------
City | BURLESON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76028-7012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-293-4800
-----------------------------------------------------
Fax | 817-293-4808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 646
-----------------------------------------------------
City | CROWLEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76036-0646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-293-4800
-----------------------------------------------------
Fax | 817-293-4808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | DR. LALITHA JAGADISH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 817-293-4800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------