Provider Demographics
NPI:1922309632
Name:BASANTI VRUSHAB MD PLLC
Entity Type:Organization
Organization Name:BASANTI VRUSHAB MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-281-4910
Mailing Address - Street 1:1615 PRECINCT LINE RD
Mailing Address - Street 2:STE 101
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3345
Mailing Address - Country:US
Mailing Address - Phone:817-281-4910
Mailing Address - Fax:817-281-3107
Practice Address - Street 1:1615 PRECINCT LINE RD
Practice Address - Street 2:STE 101
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3345
Practice Address - Country:US
Practice Address - Phone:817-281-4910
Practice Address - Fax:817-281-3107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-11
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6940207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty