Provider Demographics
NPI:1871820423
Name:BREAST DIAGNOSTICS, PA
Entity Type:Organization
Organization Name:BREAST DIAGNOSTICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PRIYA
Authorized Official - Middle Name:R
Authorized Official - Last Name:VENUGOPAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-749-2000
Mailing Address - Street 1:1545 E SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6422
Mailing Address - Country:US
Mailing Address - Phone:817-749-2000
Mailing Address - Fax:817-749-2020
Practice Address - Street 1:1750 BROAD PARK CIR S
Practice Address - Street 2:SUITE 300
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-7822
Practice Address - Country:US
Practice Address - Phone:817-749-2000
Practice Address - Fax:817-749-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM00778174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty