=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831406016
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASA DEEP KOGANTI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2010
-----------------------------------------------------
Last Update Date | 12/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1250 8TH AVE STE 135
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-4156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-921-2153
-----------------------------------------------------
Fax | 214-579-6993
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1505 LBJ FWY STE 700
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75234-6065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-366-6012
-----------------------------------------------------
Fax | 214-579-6941
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | Q5458
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------