Basic Information
| Provider Information | |||||||||
| NPI: | 1962823955 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DR. VAMSEEN JETTI PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3610 GILLESPIE ST | ||||||||
| Address2: | #3 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752194839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2025053884 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6200 W PARKER RD | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750938185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9726687460 | ||||||||
| FaxNumber: | 9726687467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2013 | ||||||||
| LastUpdateDate: | 12/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | JETTI | ||||||||
| AuthorizedOfficialFirstName: | VAMSEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2025053884 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | P6981 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | P6981 | 01 | TX | LICENSE | OTHER |