1144394529 NPI number — DR. PHYLLIS J TROTTER AU. D./ CCC-A

Table of content: DR. PHYLLIS J TROTTER AU. D./ CCC-A (NPI 1144394529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144394529 NPI number — DR. PHYLLIS J TROTTER AU. D./ CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TROTTER
Provider First Name:
PHYLLIS
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
AU. D./ CCC-A
Provider Gender Code:
F

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:
1144394529
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1136 E GRANDE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75703-3982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-592-5601
Provider Business Mailing Address Fax Number:
903-595-3304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1136 E GRANDE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75703-3982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-592-5601
Provider Business Practice Location Address Fax Number:
903-595-3304
Provider Enumeration Date:
11/20/2006

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: 231H00000X , with the licence number:  3575 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 231H00000X , with the licence number: 80550 , 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: 322324001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 80859A . This is a "BCBS BLUE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 54903 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 75-2616977-009 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P01226413 . This is a "MEDICARE RAIL ROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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