=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417951393
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONE STAR INTERNAL MEDICINE ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 617 CLARA BARTON BLVD STE 102
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75042-5761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-485-4440
-----------------------------------------------------
Fax | 972-485-4443
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 617 CLARA BARTON BLVD STE 102
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75042-5761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-485-4440
-----------------------------------------------------
Fax | 972-485-4443
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ARCHANA THOTA
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 972-485-4440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | L0950
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------