1093894198 NPI number — DR. DAVID L JANSSEN M.D.

Table of content: DR. DAVID L JANSSEN M.D. (NPI 1093894198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093894198 NPI number — DR. DAVID L JANSSEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JANSSEN
Provider First Name:
DAVID
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093894198
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1502 E RED RIVER ST
Provider Second Line Business Mailing Address:
#347
Provider Business Mailing Address City Name:
VICTORIA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77901-5523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-576-9812
Provider Business Mailing Address Fax Number:
361-574-1580

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2807 N BEN WILSON ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
VICTORIA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77901-5730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-576-9812
Provider Business Practice Location Address Fax Number:
361-574-1580
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0203X , with the licence number:  G3494 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 125696802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 760387962 . This is a "EMPLOYER ID - ROAGC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 920000190 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 742569553 . This is a "EMPLOYER ID - ROAST" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 88R662 . This is a "BLUE CROSS/SHIELD - ROAGC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 125696801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 85R632 . This is a "BLUE CROSS/SHIELD - ROAST" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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