1508890658 NPI number — DR. TRAVIS CRAIG WEDDINGTON M.D.

Table of content: DR. HEIDI BRUNETTE PSYD (NPI 1205198900)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508890658 NPI number — DR. TRAVIS CRAIG WEDDINGTON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEDDINGTON
Provider First Name:
TRAVIS
Provider Middle Name:
CRAIG
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:
1508890658
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 IRVING ST
Provider Second Line Business Mailing Address:
G220A
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
20010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-877-7783
Provider Business Mailing Address Fax Number:
301-929-0348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 IRVING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-877-7783
Provider Business Practice Location Address Fax Number:
301-929-0348
Provider Enumeration Date:
07/11/2006

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: 207L00000X , with the licence number:  MD21872 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 121990100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200107 . This is a "KAISER" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 5336451 . This is a "AETNA NON HMO" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 0071 . This is a "CAREFIRST BCBS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 022155300 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 501358 . This is a "NCPPO" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 5706670 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 441114 . This is a "ANTHEM BCBS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 2495271 . This is a "AETNA HMO" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 114470400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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