Provider Demographics
NPI:1205023397
Name:INTERNAL MEDICINE ASSOCIATES OF SOUTH DALLAS PA
Entity Type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES OF SOUTH DALLAS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHWANI
Authorized Official - Middle Name:DAYAL
Authorized Official - Last Name:SRIVASTAVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-697-7985
Mailing Address - Street 1:4305 W WHEATLAND RD
Mailing Address - Street 2:SUITE NUMBER 101
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3303
Mailing Address - Country:US
Mailing Address - Phone:214-697-7985
Mailing Address - Fax:972-708-9498
Practice Address - Street 1:4305 W WHEATLAND RD
Practice Address - Street 2:SUITE NUMBER 101
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3303
Practice Address - Country:US
Practice Address - Phone:214-697-7985
Practice Address - Fax:972-708-9498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3488207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150972102Medicaid
TX0047QWOtherBCBS
1467507038OtherINDIVIDUAL NPI NUMBER
TX191673601Medicaid
1467507038OtherINDIVIDUAL NPI NUMBER
TX191673601Medicaid
TX8714B6Medicare PIN