1780942474 NPI number — HATTIE JILL FEETHAM M.D.

Table of content: HATTIE JILL FEETHAM M.D. (NPI 1780942474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780942474 NPI number — HATTIE JILL FEETHAM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FEETHAM
Provider First Name:
HATTIE
Provider Middle Name:
JILL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DUNN
Provider Other First Name:
HATTIE
Provider Other Middle Name:
JILL
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:
1780942474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8201 PRESTON RD STE 350
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75225-6225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-631-7546
Provider Business Mailing Address Fax Number:
214-631-8546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8201 PRESTON RD STE 350
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75225-6225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-631-7546
Provider Business Practice Location Address Fax Number:
214-631-8546
Provider Enumeration Date:
05/01/2012

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: 207N00000X , with the licence number:  565428 , 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: 565428 . This is a "TMB ID#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: Q6505 . This is a "TMB" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".