1497719371 NPI number — LINDA DAVIS PA

Table of content: LINDA DAVIS PA (NPI 1497719371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497719371 NPI number — LINDA DAVIS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
LINDA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1497719371
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
903 SUMMIT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76102-3421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-877-5353
Provider Business Mailing Address Fax Number:
817-877-5357

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
903 SUMMIT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76102-3421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-877-5353
Provider Business Practice Location Address Fax Number:
817-877-5357
Provider Enumeration Date:
04/17/2006

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: 363AM0700X , with the licence number:  PA02755 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA02755 , 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: 8N2936 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 196496702 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 196496703 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 196496701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 196496704 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00137420 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 196496705 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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