Provider Demographics
NPI:1881860484
Name:DASARI, VIJAYA M (MD)
Entity Type:Individual
Prefix:
First Name:VIJAYA
Middle Name:M
Last Name:DASARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3304 COLORADO BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-6877
Mailing Address - Country:US
Mailing Address - Phone:940-898-7488
Mailing Address - Fax:940-243-3554
Practice Address - Street 1:2701 SHORELINE DR
Practice Address - Street 2:101
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210
Practice Address - Country:US
Practice Address - Phone:940-898-7488
Practice Address - Fax:940-247-3006
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1604207RG0100X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX320029703Medicaid
OHP00735158Medicare PIN
OHDA4265641Medicare PIN