Basic Information
Provider Information
NPI: 1083890636
EntityType: 2
ReplacementNPI:  
OrganizationName: OB GYN DALLAS, P.A.
LastName:  
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Mailing Information
Address1: 8160 WALNUT HILL LN
Address2: SUITE 219
City: DALLAS
State: TX
PostalCode: 752314339
CountryCode: US
TelephoneNumber: 2143692400
FaxNumber: 2143697528
Practice Location
Address1: 8160 WALNUT HILL LN
Address2: SUITE 219
City: DALLAS
State: TX
PostalCode: 752314339
CountryCode: US
TelephoneNumber: 2143692400
FaxNumber: 2143697528
Other Information
ProviderEnumerationDate: 01/14/2008
LastUpdateDate: 01/14/2008
NPIDeactivationReasonCode:  
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ProviderGenderCode:  
AuthorizedOfficialLastName: DULLYE
AuthorizedOfficialFirstName: TARA
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 2143692400
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: M.D.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207V00000XK4325TXY193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansObstetrics & Gynecology 

ID Information
IDTypeStateIssuerDescription
169346705TX MEDICAID


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