1376556019 NPI number — DR. STATON AWTREY M.D.

Table of content: DR. STATON AWTREY M.D. (NPI 1376556019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376556019 NPI number — DR. STATON AWTREY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AWTREY
Provider First Name:
STATON
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1376556019
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4214 ANDREWS HWY STE 240
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79703-4817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-686-6600
Provider Business Mailing Address Fax Number:
432-682-2284

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 ROSALIND REDFERN GROVER PKWY STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79701-5852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-221-2107
Provider Business Practice Location Address Fax Number:
432-221-5218
Provider Enumeration Date:
08/14/2006

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: 207RC0000X , with the licence number:  H6019 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X , with the licence number: H6019 , 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: 147713503 . This is a "MEDICAID - MIDLAND - PFC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8663J0 . This is a "BCBS AUSTIN ID NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8663JO . This is a "MEDICARE PIN SAN ANGELO" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TXB138584 . This is a "TX MEDICARE-PREMIER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 85010X . This is a "BCBS SAN ANGELO ID NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TXB138584 . This is a "MIDLAND MEDICARE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 147713501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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