1760485502 NPI number — DR. ERIC J VENEGAS M.D

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760485502 NPI number — DR. ERIC J VENEGAS M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VENEGAS
Provider First Name:
ERIC
Provider Middle Name:
J
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:
1760485502
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/16/2006
NPI Reactivation Date:
04/05/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 80969
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79708-0969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-570-1113
Provider Business Mailing Address Fax Number:
432-570-4260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5007 PORTICO WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-570-1113
Provider Business Practice Location Address Fax Number:
432-570-4260
Provider Enumeration Date:
05/24/2005

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: 174400000X , with the licence number:  K7934 , 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: 144105701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: TH003 . This is a "FIRSTCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0052GV . This is a "BLUE CROSS BLUE SHIELD OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".