=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659823128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LODESPOTO MEDICAL, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2016
-----------------------------------------------------
Last Update Date | 10/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 CONGRESS AVE STE 2000
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78701-2745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-503-4419
-----------------------------------------------------
Fax | 844-753-4371
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 958
-----------------------------------------------------
City | PORT JEFFERSON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11776-0811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-503-4419
-----------------------------------------------------
Fax | 844-753-4371
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARK LODESPOTO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 972-503-4419
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085N0700X
-----------------------------------------------------
Taxonomy Name | Neuroradiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------