=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396770947
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARINA TOMY VENGALIL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2006
-----------------------------------------------------
Last Update Date | 01/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 CLARA BARTON BLVD STE 145
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75042-5755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-560-9400
-----------------------------------------------------
Fax | 972-560-9401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 360541
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15251-6541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-525-9900
-----------------------------------------------------
Fax | 469-333-7988
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | K9693
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | K9693
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------