=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396142774
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH TEXAS GASTROENTEROLOGY, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2014
-----------------------------------------------------
Last Update Date | 09/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3304 COLORADO BLVD STE 205
-----------------------------------------------------
City | DENTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76210-6877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-898-7488
-----------------------------------------------------
Fax | 940-243-3554
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3304 COLORADO BLVD STE 205
-----------------------------------------------------
City | DENTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76210-6877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-898-7488
-----------------------------------------------------
Fax | 940-243-3554
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GASTROENTEROLOGY
-----------------------------------------------------
Name | DR. VIJAYA M DASARI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 409-338-5657
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | N1604
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------