Basic Information
| Provider Information | |||||||||
| NPI: | 1396770947 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VENGALIL | ||||||||
| FirstName: | MARINA | ||||||||
| MiddleName: | TOMY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9101 LBJ FWY STE 710 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752431912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727925700 | ||||||||
| FaxNumber: | 2145061170 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 CLARA BARTON BLVD STE 145 | ||||||||
| Address2: | |||||||||
| City: | GARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725609400 | ||||||||
| FaxNumber: | 9725609401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 07/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | K9693 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | K9693 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 143930903 | 05 | TX | MEDICAID |