1508865536 NPI number — DR. JOHN DOUGLAS OVERBECK M.D.

Table of content: DR. JOHN DOUGLAS OVERBECK M.D. (NPI 1508865536)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508865536 NPI number — DR. JOHN DOUGLAS OVERBECK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OVERBECK
Provider First Name:
JOHN
Provider Middle Name:
DOUGLAS
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:
OVERBECK
Provider Other First Name:
J. DOUGLAS
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1508865536
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 TUSCAN DR STE 205
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:
75039-3838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-253-2505
Provider Business Mailing Address Fax Number:
833-944-1908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 TUSCAN
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75039-3834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-253-2505
Provider Business Practice Location Address Fax Number:
833-944-1908
Provider Enumeration Date:
07/20/2005

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: 207RC0000X , with the licence number:  G9376 , 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: 1354078 03 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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