MEDICARE: DR. TAREK O SOURYAL

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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	G3079	TX

General Provider Information

NPI Number	:	1376543090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TAREK O SOURYAL

Provider Business Mailing Address
First Line	:	6901 SNIDER PLZ
Second Line	:	#200
City	:	DALLAS
State	:	TX
Zip	:	75205-5648
Country	:	US
Telephone Number	:	214-369-7733
Fax Number	:	214-369-7739

Provider Business Practice Location Address
First Line	:	6901 SNIDER PLZ
Second Line	:	#200
City	:	DALLAS
State	:	TX
Zip	:	75205-5648
Country	:	US
Telephone Number	:	214-369-7733
Fax Number	:	214-369-7739

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

Provider Enumeration Date	:	07/22/2005
Last Update Date	:	07/08/2007

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