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General NPI Number Information
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NPI Number | 1508411083
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Entity Type | Organization
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Legal Business Name | INNOVISTA PROVIDER GROUP TEXAS PA
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Dates
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Enumeration Date | 08/01/2019
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Last Update Date | 06/02/2025
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Provider Practice Location Address
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Address Line | 350 S PLANO RD
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City | RICHARDSON
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State | TX
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Zip | 75081-4505
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Country | US
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Telephone | 305-470-2929
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 8150
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City | WESTCHESTER
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State | IL
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Zip | 60154-8150
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Country | US
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Telephone | 844-665-4827
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Fax | 877-862-5671
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Authorized Official
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Title or Position | MARKET MEDICAL DIRECTOR
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Name | AFREEN PAPPA
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Credential |
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Telephone | 281-639-4679
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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