=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932939824
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SRDO ADVANCED WOUND CARE ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2024
-----------------------------------------------------
Last Update Date | 08/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4310 BUENA VISTA ST APT 34
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75205-4473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-525-1010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4310 BUENA VISTA ST APT 34
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75205-4473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-525-1010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CMO
-----------------------------------------------------
Name | DR. STEVEN WILLIAM ROBERTS
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 979-525-1010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------