Provider Demographics
NPI:1891900080
Name:WEST TEXAS DIABETES AND ENDOCRINE CENTER PA
Entity Type:Organization
Organization Name:WEST TEXAS DIABETES AND ENDOCRINE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MURALIDHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUSALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-332-1144
Mailing Address - Street 1:318 N ALLEGHANEY AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5027
Mailing Address - Country:US
Mailing Address - Phone:432-332-1144
Mailing Address - Fax:432-337-2726
Practice Address - Street 1:318 N ALLEGHANEY AVE STE 201
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5027
Practice Address - Country:US
Practice Address - Phone:432-332-1144
Practice Address - Fax:432-337-2726
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST TEXAS DIABETES AND ENDOCRINE CENTER PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6230174400000X
TXK6228174400000X
TXK3962207QA0505X
TXJ1178207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030349701Medicaid
TX126502701Medicaid
TX080422101Medicaid
TX00450LMedicare PIN
TX126502701Medicaid
0A3984Medicare PIN