1285694984 NPI number — GWENDOLYN J ALLEN MD

Table of content: GWENDOLYN J ALLEN MD (NPI 1285694984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285694984 NPI number — GWENDOLYN J ALLEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLEN
Provider First Name:
GWENDOLYN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1285694984
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1604 14TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROWNWOOD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76801-5314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-646-5296
Provider Business Mailing Address Fax Number:
325-646-5820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1604 14TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROWNWOOD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76801-5314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-646-5296
Provider Business Practice Location Address Fax Number:
325-646-5820
Provider Enumeration Date:
03/25/2006

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: 207Q00000X , with the licence number:  G4784 , 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: 127751908 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: G4784 . This is a "TEXAS MEDICAL LIC #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 252944274 . This is a "BCBS #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11368850 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: H08CG76301 . This is a "BCBSTX PCP" identifier . This identifiers is of the category "OTHER".
  • Identifier: D0060429 . This is a "TX DPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: H00061TE01 . This is a "BC PROVIDER #" identifier . This identifiers is of the category "OTHER".




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