Provider Demographics
NPI:1093050148
Name:DHAVALESHWAR, DEEPTI
Entity Type:Individual
Prefix:
First Name:DEEPTI
Middle Name:
Last Name:DHAVALESHWAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7610 N STEMMONS FWY STE 600
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4228
Mailing Address - Country:US
Mailing Address - Phone:214-689-5960
Mailing Address - Fax:469-713-8084
Practice Address - Street 1:981 STATE HIGHWAY 121
Practice Address - Street 2:SUITE 1140
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013
Practice Address - Country:US
Practice Address - Phone:469-697-5100
Practice Address - Fax:469-697-5105
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-30
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD452033207RG0100X
TXR8553207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102968788Medicaid
PA102968788Medicaid
PA1029687880002Medicaid