=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265461370
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHWEST UROLOGY ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2006
-----------------------------------------------------
Last Update Date | 12/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1411 N BECKLEY AVE SUITE 464
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75203-1259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-948-3101
-----------------------------------------------------
Fax | 214-941-7633
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 678164
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75267-8164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-948-3101
-----------------------------------------------------
Fax | 214-941-7633
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | PATRICIA A. VARA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-948-3101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------