Provider Demographics
NPI:1649093832
Name:IDMDTX, PLLC
Entity type:Organization
Organization Name:IDMDTX, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MILONI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHROFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-943-2570
Mailing Address - Street 1:4843 COLLEYVILLE BLVD # 251-103
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-3923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1307 8TH AVE STE 306
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4140
Practice Address - Country:US
Practice Address - Phone:813-943-2570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-05
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty