1043296122 NPI number — DR. DEREK R LINKLATER M.D.

Table of content: DR. DEREK R LINKLATER M.D. (NPI 1043296122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043296122 NPI number — DR. DEREK R LINKLATER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LINKLATER
Provider First Name:
DEREK
Provider Middle Name:
R
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:
1043296122
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2205 RAVENHILL CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76513-1307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-493-4472
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36065 SANTA FE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT HOOD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76544-5060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-493-4472
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/20/2005

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: 207P00000X , with the licence number:  L7799 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207PP0204X , with the licence number: L7799 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2080P0204X , with the licence number: L7799 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 164764604 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8C0840 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 164777801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".