1477655751 NPI number — JAMES F CITEK O D

Table of content: JAMES F CITEK O D (NPI 1477655751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477655751 NPI number — JAMES F CITEK O D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CITEK
Provider First Name:
JAMES
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O 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:
1477655751
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1818 N VELASCO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANGLETON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77515-3015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-849-2331
Provider Business Mailing Address Fax Number:
979-849-7520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1818 N VELASCO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANGLETON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77515-3015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-849-2331
Provider Business Practice Location Address Fax Number:
979-849-7520
Provider Enumeration Date:
09/05/2006

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: 152WV0400X , with the licence number:  2698-TG , 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: 80749Q . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 112482804 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 155956901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".