=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780045401
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EPIC PRIMARY CARE OF TEXAS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2016
-----------------------------------------------------
Last Update Date | 03/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3504 SPRINGBRANCH DR
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75082-2430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-268-0591
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3504 SPRINGBRANCH DR
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75082-2430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SOLE PROPRIETER
-----------------------------------------------------
Name | AYESHA JAMAL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 972-268-0591
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | N2580
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------