Provider Demographics
NPI:1942405436
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:
Authorized Official - Last Name:VENUGOPAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-483-9550
Mailing Address - Street 1:1545 E SOUTHLAKE BLVD
Mailing Address - Street 2:STE 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:817-749-2000
Practice Address - Street 1:2817 S MAYHILL RD
Practice Address - Street 2:STE 270
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76208-5966
Practice Address - Country:US
Practice Address - Phone:940-483-9500
Practice Address - Fax:940-483-9550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5600174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH31009Medicare UPIN
TX00739ZMedicare ID - Type UnspecifiedPRACTICE MEDICARE #
TX8F1573Medicare ID - Type UnspecifiedPROVIDER #