1619927373 NPI number — GEORGE SOUHEL KHAMMAR MD

Table of content: ANDY YIN (NPI 1902650294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619927373 NPI number — GEORGE SOUHEL KHAMMAR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHAMMAR
Provider First Name:
GEORGE
Provider Middle Name:
SOUHEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1619927373
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1017 12TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104-3915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-334-2800
Provider Business Mailing Address Fax Number:
817-820-0094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1017 12TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-3915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-334-2800
Provider Business Practice Location Address Fax Number:
817-820-0094
Provider Enumeration Date:
05/11/2006

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: 207RC0000X , with the licence number:  L4489 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: L4489 , 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: 1558264-02 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10008961 . This is a "AMERIGROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1558264-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7462025 . This is a "AETNA PROVIDER ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8G2851 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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