MEDICARE: SOUMYA DATTANAGOWDA DANDOTHI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207R00000X	Internal Medicine Physician	V2050	TX

General Provider Information

NPI Number	:	1306519822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOUMYA DATTANAGOWDA DANDOTHI MD

Provider Business Mailing Address
First Line	:	2423 WILLIAMS DR STE 107
Second Line	:
City	:	GEORGETOWN
State	:	TX
Zip	:	78628-3269
Country	:	US
Telephone Number	:	877-800-5722
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 OAK SPRINGS DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78702-2537
Country	:	US
Telephone Number	:	877-800-5722
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2021
Last Update Date	:	06/27/2025

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