1558342634 NPI number — DR. ALEX CLARK WILLINGHAM M.D.

Table of content: DR. ALEX CLARK WILLINGHAM M.D. (NPI 1558342634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558342634 NPI number — DR. ALEX CLARK WILLINGHAM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLINGHAM
Provider First Name:
ALEX
Provider Middle Name:
CLARK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.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:
1558342634
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 SPURS LANE BLDG 6 SUITE 100
Provider Second Line Business Mailing Address:
SOUTH TEXAS PM&R GROUP, INC.
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-615-2225
Provider Business Mailing Address Fax Number:
210-615-8432

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 SPURS LANE BLDG 6 SUITE 100
Provider Second Line Business Practice Location Address:
SOUTH TEXAS PM&R GROUP, INC.
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-615-2225
Provider Business Practice Location Address Fax Number:
210-615-8432
Provider Enumeration Date:
11/07/2005

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: 208100000X , with the licence number:  H1249 , 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: 1348369-02 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: H1249 . This is a "TEXAS MEDICAL LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".