1326120734 NPI number — ANGELA DAWN EARHART M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326120734 NPI number — ANGELA DAWN EARHART M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EARHART
Provider First Name:
ANGELA
Provider Middle Name:
DAWN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
IANCULOVILI
Provider Other First Name:
ANGELA
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1326120734
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 KINGWOOD MEDICAL DRIVE
Provider Second Line Business Mailing Address:
SUITE 215
Provider Business Mailing Address City Name:
KINGWOOD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77339-4412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-978-5611
Provider Business Mailing Address Fax Number:
281-205-0204

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 KINGWOOD MEDICAL DRIVE
Provider Second Line Business Practice Location Address:
SUITE 215
Provider Business Practice Location Address City Name:
KINGWOOD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77339-4412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-978-5611
Provider Business Practice Location Address Fax Number:
281-205-0204
Provider Enumeration Date:
10/19/2006

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: 207VM0101X , with the licence number:  M4767 , 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: 8BZ693 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 185571006 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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