1386646107 NPI number — DR. CHARLES P VANDUYNE M.D.

Table of content: DR. CHARLES P VANDUYNE M.D. (NPI 1386646107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386646107 NPI number — DR. CHARLES P VANDUYNE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDUYNE
Provider First Name:
CHARLES
Provider Middle Name:
P
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:
1386646107
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4300 CITY POINT DRIVE
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
NORTH RICHLAND HILLS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76180-8359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-284-8222
Provider Business Mailing Address Fax Number:
817-595-5718

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4300 CITY POINT DRIVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
NORTH RICHLAND HILLS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76180-8359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-284-8222
Provider Business Practice Location Address Fax Number:
817-595-5718
Provider Enumeration Date:
08/11/2005

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: 207V00000X , with the licence number:  H0020 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X , with the licence number: 135371 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: TXB149541 . This is a "MEDICARE UNDER GROUP 00U61E" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 113843008 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 113843007 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 113843006 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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