=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679528467
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAJESH GOGIA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2006
-----------------------------------------------------
Last Update Date | 05/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3025 MATLOCK RD STE 100
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76015-2902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-502-8157
-----------------------------------------------------
Fax | 972-739-1468
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2140 E SOUTHLAKE BLVD STE L-309
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-6516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-502-8157
-----------------------------------------------------
Fax | 972-739-1468
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | M5724
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 057464
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------