Provider Demographics
NPI:1871099739
Name:SOUTHLAKE ORTHOPEDICS & SPORTS MEDICINE, PLLC
Entity type:Organization
Organization Name:SOUTHLAKE ORTHOPEDICS & SPORTS MEDICINE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BANTOO
Authorized Official - Middle Name:
Authorized Official - Last Name:SEHGAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-631-9881
Mailing Address - Street 1:2600 E SOUTHLAKE BLVD STE 120-177
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6634
Mailing Address - Country:US
Mailing Address - Phone:214-631-9881
Mailing Address - Fax:469-466-6101
Practice Address - Street 1:2120 N MACARTHUR BLVD STE 100
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-2260
Practice Address - Country:US
Practice Address - Phone:214-631-9881
Practice Address - Fax:972-438-2077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-31
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR0125207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty