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General NPI Number Information
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NPI Number | 1871820423
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Entity Type | Organization
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Legal Business Name | BREAST DIAGNOSTICS, PA
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Dates
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Enumeration Date | 11/03/2009
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Last Update Date | 11/03/2009
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Provider Practice Location Address
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Address Line | 1750 BROAD PARK CIR S SUITE 300
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City | MANSFIELD
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State | TX
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Zip | 76063-7822
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Country | US
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Telephone | 817-749-2000
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Fax | 817-749-2020
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Provider Business Mailing Address
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Address Line | 1545 E SOUTHLAKE BLVD SUITE 200
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City | SOUTHLAKE
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State | TX
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Zip | 76092-6422
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Country | US
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Telephone | 817-749-2000
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Fax | 817-749-2020
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Authorized Official
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Title or Position | PRESIDENT
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Name | PRIYA R VENUGOPAL
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Credential | MD
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Telephone | 817-749-2000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | M00778
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License Number State | TX
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