Basic Information
| Provider Information | |||||||||
| NPI: | 1780772277 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JASTI | ||||||||
| FirstName: | SUSHAMA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 W MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177597000 | ||||||||
| FaxNumber: | 8177597000 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 N. I-35, #111 | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403808155 | ||||||||
| FaxNumber: | 9403808159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | M4206 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207R00000X | M4206 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.