1366430332 NPI number — MELITA LANG BROOKS MD

Table of content: MELITA LANG BROOKS MD (NPI 1366430332)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366430332 NPI number — MELITA LANG BROOKS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROOKS
Provider First Name:
MELITA
Provider Middle Name:
LANG
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:
LANG
Provider Other First Name:
MELITA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366430332
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2014
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:
3202 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINDALE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75771-7727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-882-0991
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2005

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: 207Q00000X , with the licence number:  J1501 , 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: 117314 . This is a "CHIPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 752616977028 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 103402703 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 138737515 . This is a "EPSDT" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8S1460 . This is a "BCBS OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".