=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780043695
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRODIGY WELLNESS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2016
-----------------------------------------------------
Last Update Date | 02/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4040 LEGACY DR SUITE 204
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75034-6748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-978-0796
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4040 LEGACY DR SUITE 204
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75034-6748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-978-0796
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SAMAD KHAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 585-978-0796
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | Q6046
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------