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General NPI Number Information
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NPI Number | 1912108234
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Entity Type | Individual
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Provider Name | VISHWAROOP BANTU MD
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Gender | Male
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Dates
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Enumeration Date | 05/31/2007
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Last Update Date | 03/09/2021
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Provider Practice Location Address
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Address Line | 11801 SOUTH FWY
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City | BURLESON
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State | TX
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Zip | 76028-7021
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Country | US
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Telephone | 817-568-5955
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Fax |
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Provider Business Mailing Address
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Address Line | 713 ARMSTRONG BLVD
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City | COPPELL
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State | TX
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Zip | 75019-4536
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Country | US
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Telephone | 269-377-7022
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | P4735
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 4301089645
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License Number State | MI
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