Provider Demographics
NPI:1942685409
Name:ADVANCED GASTROENTEROLOGY OF TEXAS PLLC
Entity Type:Organization
Organization Name:ADVANCED GASTROENTEROLOGY OF TEXAS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FARBOD
Authorized Official - Middle Name:
Authorized Official - Last Name:MASROUR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:214-320-7680
Mailing Address - Street 1:PO BOX 801344
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75380-1344
Mailing Address - Country:US
Mailing Address - Phone:214-962-4863
Mailing Address - Fax:214-758-1400
Practice Address - Street 1:2698 NORTH GALLOWAY
Practice Address - Street 2:SUITE 103
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150
Practice Address - Country:US
Practice Address - Phone:214-962-4863
Practice Address - Fax:214-758-1400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-27
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9262207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX439810Medicare PIN