1790779015 NPI number — DR. PAUL LESLIE DEGENAER O.D.

Table of content: DR. PAUL LESLIE DEGENAER O.D. (NPI 1790779015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790779015 NPI number — DR. PAUL LESLIE DEGENAER O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEGENAER
Provider First Name:
PAUL
Provider Middle Name:
LESLIE
Provider Name Prefix Text:
DR.
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:
DEGENAER
Provider Other First Name:
PAUL
Provider Other Middle Name:
LESLIE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1790779015
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1902 MERRIMAC TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75043-1233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-547-4200
Provider Business Mailing Address Fax Number:
972-547-4202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5001 MCKINNEY RANCH PKWY
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MCKINNEY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75070-8601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-547-4200
Provider Business Practice Location Address Fax Number:
972-547-4202
Provider Enumeration Date:
09/01/2005

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: 152WC0802X , with the licence number:  4630T , 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)