Provider Demographics
NPI:1396206264
Name:CARRASCO, DANIELA
Entity Type:Individual
Prefix:
First Name:DANIELA
Middle Name:
Last Name:CARRASCO
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 1:803 W DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-4954
Mailing Address - Country:US
Mailing Address - Phone:469-372-6200
Mailing Address - Fax:469-372-6203
Practice Address - Street 1:803 W DAVIS ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-4954
Practice Address - Country:US
Practice Address - Phone:469-372-6200
Practice Address - Fax:469-372-6203
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-25
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT7881207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program