Basic Information
| Provider Information | |||||||||
| NPI: | 1710908744 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEHNAM | ||||||||
| FirstName: | SOROUSH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 CITY POINT DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | NORTH RICHLAND HILLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761808380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172551940 | ||||||||
| FaxNumber: | 4697138379 | ||||||||
| Practice Location | |||||||||
| Address1: | 9250 AMBERTON PKWY | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752433224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6822363656 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | L7663 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 168068806 | 05 | TX | MEDICAID | 168068803 | 05 | TX | MEDICAID | 168068809 | 05 | TX | MEDICAID | 179478601 | 05 | TX | MEDICAID | 168068801 | 05 | TX | MEDICAID | 168068802 | 05 | TX | MEDICAID | 168068804 | 05 | TX | MEDICAID | 168068807 | 05 | TX | MEDICAID | 168068808 | 05 | TX | MEDICAID |