1073778288 NPI number — MR. DAVID GEORGE MARKOVICH JR. P.T.

Table of content: MR. DAVID GEORGE MARKOVICH JR. P.T. (NPI 1073778288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073778288 NPI number — MR. DAVID GEORGE MARKOVICH JR. P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARKOVICH
Provider First Name:
DAVID
Provider Middle Name:
GEORGE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
P.T.
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:
1073778288
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76063-0150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-995-3793
Provider Business Mailing Address Fax Number:
817-563-2409

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
811 W INTERSTATE 20
Provider Second Line Business Practice Location Address:
SUITE 136
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76017-5870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-995-3793
Provider Business Practice Location Address Fax Number:
817-563-2409
Provider Enumeration Date:
07/28/2008

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: 225100000X , with the licence number:  1100832 , 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)





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