Provider Demographics
NPI:1922028687
Name:PATHAK, PUSHPA R (MD)
Entity Type:Individual
Prefix:
First Name:PUSHPA
Middle Name:R
Last Name:PATHAK
Suffix:
Gender:M
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:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5201 HARRY HINES BLVD
Practice Address - Street 2:AMBULATORY CARE CLINIC
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7708
Practice Address - Country:US
Practice Address - Phone:214-590-5512
Practice Address - Fax:214-590-5491
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5509207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181620903Medicaid
TX8K4032OtherBLUE CROSS BLUE SHIELD
TX181620901Medicaid
TX181620902Medicaid
TX181620902Medicaid
TX8K4032OtherBLUE CROSS BLUE SHIELD