Provider Demographics
NPI:1255399945
Name:DAFTARY, PRAMILA K (MD)
Entity type:Individual
Prefix:DR
First Name:PRAMILA
Middle Name:K
Last Name:DAFTARY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 JEWELL DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-6630
Mailing Address - Country:US
Mailing Address - Phone:254-753-3646
Mailing Address - Fax:254-753-1411
Practice Address - Street 1:221 JEWELL DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-6630
Practice Address - Country:US
Practice Address - Phone:254-753-3646
Practice Address - Fax:254-753-1411
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1639174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG1639OtherLICENSE
TX080984001Medicaid
TX00675KMedicare ID - Type UnspecifiedMEDICARE
TXG1639OtherLICENSE