Provider Demographics
NPI:1396010526
Name:DASARI, VIVEKANAND (MD)
Entity Type:Individual
Prefix:
First Name:VIVEKANAND
Middle Name:
Last Name:DASARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VIVEKANAND
Other - Middle Name:
Other - Last Name:DASARI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:701 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-4206
Mailing Address - Country:US
Mailing Address - Phone:432-355-5270
Mailing Address - Fax:
Practice Address - Street 1:701 W 5TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-4206
Practice Address - Country:US
Practice Address - Phone:432-355-5270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP2223208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics