1083604458 NPI number — VIRGIL B MEDLOCK MD

Table of content: VIRGIL B MEDLOCK MD (NPI 1083604458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083604458 NPI number — VIRGIL B MEDLOCK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDLOCK
Provider First Name:
VIRGIL
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1083604458
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 650500
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:
75265-0500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-369-8555
Provider Business Mailing Address Fax Number:
214-369-2683

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3900 JUNIUS ST
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75246-1615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-823-7090
Provider Business Practice Location Address Fax Number:
214-823-1644
Provider Enumeration Date:
10/26/2005

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: 207X00000X , with the licence number:  K3615 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XS0106X , with the licence number: K3615 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XS0114X , with the licence number: K3615 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: K3615 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0801X , with the licence number: K3615 , 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: 8A5019 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 152255901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 152255902 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 152255903 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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