Provider Demographics
NPI:1790077279
Name:MANOHAR VAJJA, MD PA
Entity Type:Organization
Organization Name:MANOHAR VAJJA, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANOHAR
Authorized Official - Middle Name:PRASAD
Authorized Official - Last Name:VAJJA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-910-9341
Mailing Address - Street 1:6447 MALAGA
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-3191
Mailing Address - Country:US
Mailing Address - Phone:972-910-9341
Mailing Address - Fax:972-499-2500
Practice Address - Street 1:6447 MALAGA
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-3191
Practice Address - Country:US
Practice Address - Phone:972-910-9341
Practice Address - Fax:972-499-2500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7714207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB130027OtherMEDICARE PART B
TXM7714OtherLICENCE
TXTXB130028Medicare PIN