1285667089 NPI number — JACY L RETZ MD

Table of content: JACY L RETZ MD (NPI 1285667089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285667089 NPI number — JACY L RETZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RETZ
Provider First Name:
JACY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1285667089
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 846098
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-6098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-324-6450
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 W MEDICAL CENTER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEBSTER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77598-4220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-371-7879
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/08/2006

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: 207RP1001X , with the licence number:  2002001742 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: 2002001742 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: N5358 , 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: 1285667089 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 217643003 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 75-2616977-042 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 810000902 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8EB371 . This is a "BCBS BLUE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 100227160A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 205785108 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100416540A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01290935 . This is a "RAIL ROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 144600 . This is a "ANTHEM" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 217643001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00898407 . This is a "MEDICARE RR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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