1104023134 NPI number — ANGELA D SELF MD

Table of content: DR. ABHILASH ABRAHAM PT, DPT (NPI 1487903415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104023134 NPI number — ANGELA D SELF MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANGELA D SELF MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1104023134
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5409 DAVIS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH RICHLAND HILLS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76180-6827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-788-1059
Provider Business Mailing Address Fax Number:
817-581-1065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5409 DAVIS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH RICHLAND HILLS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76180-6827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-788-1059
Provider Business Practice Location Address Fax Number:
817-581-1065
Provider Enumeration Date:
07/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SELF
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
817-788-1059

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0043KL . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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