1497070379 NPI number — MATTHEW QUINN OLDEN R.T. (R),(T)

Table of content: MATTHEW QUINN OLDEN R.T. (R),(T) (NPI 1497070379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497070379 NPI number — MATTHEW QUINN OLDEN R.T. (R),(T)

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLDEN
Provider First Name:
MATTHEW
Provider Middle Name:
QUINN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
R.T. (R),(T)
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OLDEN
Provider Other First Name:
MATT
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
R.T. (R),(T)
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1497070379
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4004 DORRIS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75038-4003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-308-0268
Provider Business Mailing Address Fax Number:
972-258-7972

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4004 DORRIS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75038-4003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-308-0268
Provider Business Practice Location Address Fax Number:
972-258-7972
Provider Enumeration Date:
04/02/2010

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: 2471R0002X , with the licence number:  19961 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2471R0002X , with the licence number: 233121 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 19961 . This is a "TEXAS DEPARTMENT OF HEALTH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 233121 . This is a "AMERICAN REGISTRY RADIOLOGIC TECHNOLOGIST" identifier . This identifiers is of the category "OTHER".




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