1114084431 NPI number — DUSTIN VIDRINE

Table of content: DUSTIN VIDRINE (NPI 1114084431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114084431 NPI number — DUSTIN VIDRINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VIDRINE
Provider First Name:
DUSTIN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1114084431
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 650865
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:
75265-0865
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-233-1999
Provider Business Mailing Address Fax Number:
972-233-3666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 CITYWEST BLVD
Provider Second Line Business Practice Location Address:
STE. 300
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77042-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-233-1999
Provider Business Practice Location Address Fax Number:
972-233-3666
Provider Enumeration Date:
01/03/2007

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: 367500000X , with the licence number:  AP115519 , 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)

  • Identifier: 8694UM . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P01246272 . This is a "RAIL ROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 187060202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8330UE . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 75-1976930-005 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 187060205 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 187060203 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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