1356521512 NPI number — L D ANESTHESIA, P.A.

Table of content: (NPI 1356521512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356521512 NPI number — L D ANESTHESIA, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
L D ANESTHESIA, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1356521512
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 720395
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:
75372-0395
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-438-8053
Provider Business Mailing Address Fax Number:
972-690-7857

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 N HALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75226-1339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-820-3151
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DULLYE
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
214-370-0790

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0007GH . This is a "BCBS TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8A7510 . This is a "BCBS TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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