1437117306 NPI number — DR. CAROL DAVENPORT WEIDNER MD

Table of content: DR. CAROL DAVENPORT WEIDNER MD (NPI 1437117306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437117306 NPI number — DR. CAROL DAVENPORT WEIDNER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEIDNER
Provider First Name:
CAROL
Provider Middle Name:
DAVENPORT
Provider Name Prefix Text:
DR.
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:
WEIDNER
Provider Other First Name:
CAROL
Provider Other Middle Name:
ANNETTE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1437117306
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4275 LITTLE RD
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76016-5600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-516-8811
Provider Business Mailing Address Fax Number:
817-516-8444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4275 LITTLE RD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76016-5600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-516-8811
Provider Business Practice Location Address Fax Number:
817-516-8444
Provider Enumeration Date:
05/02/2006

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: 207L00000X , with the licence number:  J0876 , 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)





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