1225009558 NPI number — TONI JEANNE MADRID LM

Table of content: TONI JEANNE MADRID LM (NPI 1225009558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225009558 NPI number — TONI JEANNE MADRID LM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADRID
Provider First Name:
TONI
Provider Middle Name:
JEANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MADRID
Provider Other First Name:
JEANNE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LM
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1225009558
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
930 BRYAN CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNDS
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74047-5392
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-366-0301
Provider Business Mailing Address Fax Number:
918-366-0301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
930 BRYAN CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNDS
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74047-5392
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-366-0301
Provider Business Practice Location Address Fax Number:
918-366-0301
Provider Enumeration Date:
01/26/2006

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: 176B00000X , with the licence number:  MW22 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 340015800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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