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General NPI Number Information
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NPI Number | 1942405436
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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 | 06/15/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2817 S MAYHILL RD STE 270
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City | DENTON
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State | TX
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Zip | 76208-5966
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Country | US
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Telephone | 940-483-9500
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Fax | 940-483-9550
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Provider Business Mailing Address
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Address Line | 1545 E SOUTHLAKE BLVD STE 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 | 817-749-2000
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Authorized Official
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Title or Position | PRESIDENT
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Name | PRIYA VENUGOPAL
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Credential | MD
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Telephone | 940-483-9550
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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 | L5600
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License Number State | TX
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