=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619573532
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DFW SPORTS MEDICINE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2020
-----------------------------------------------------
Last Update Date | 02/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4833 MEDICAL CENTER DR STE 6E
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75069-1898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-430-9380
-----------------------------------------------------
Fax | 469-242-9539
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 239 GLEN RIDGE DR
-----------------------------------------------------
City | MURPHY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75094-4206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | RATHNA NUTI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 214-738-6169
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------