Provider Demographics
NPI:1700901022
Name:NISHENDU M. VASAVADA, M.D., P.A.
Entity Type:Organization
Organization Name:NISHENDU M. VASAVADA, M.D., P.A.
Other - Org Name:LAKESIDE LIFE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-221-1741
Mailing Address - Street 1:560 W MAIN ST
Mailing Address - Street 2:STE. 101
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-3629
Mailing Address - Country:US
Mailing Address - Phone:972-221-1741
Mailing Address - Fax:972-219-0057
Practice Address - Street 1:560 W MAIN ST
Practice Address - Street 2:STE. 101
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3629
Practice Address - Country:US
Practice Address - Phone:972-221-1741
Practice Address - Fax:972-219-0057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF24902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX220087501Medicaid
TX0072MWOtherBLUE CROSS BLUE SHIELD
OK200105540AMedicaid
TXTXB113677Medicare PIN