Provider Demographics
NPI:1043644537
Name:NACHAWATI, WISAM (DO)
Entity Type:Individual
Prefix:
First Name:WISAM
Middle Name:
Last Name:NACHAWATI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5224 S STATE HIGHWAY 360 STE 230
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-0964
Mailing Address - Country:US
Mailing Address - Phone:972-522-0691
Mailing Address - Fax:972-522-1053
Practice Address - Street 1:5224 S STATE HIGHWAY 360 STE 230
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-0964
Practice Address - Country:US
Practice Address - Phone:972-522-0691
Practice Address - Fax:972-522-1053
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-03
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT1786207Q00000X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program