Provider Demographics
NPI:1780043695
Name:PRODIGY WELLNESS PLLC
Entity type:Organization
Organization Name:PRODIGY WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-978-0796
Mailing Address - Street 1:4040 LEGACY DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-6748
Mailing Address - Country:US
Mailing Address - Phone:585-978-0796
Mailing Address - Fax:
Practice Address - Street 1:4040 LEGACY DR
Practice Address - Street 2:SUITE 204
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-6748
Practice Address - Country:US
Practice Address - Phone:585-978-0796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ6046174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty