1619976966 NPI number — JACK W SPITZBERG MD

Table of content: JACK W SPITZBERG MD (NPI 1619976966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619976966 NPI number — JACK W SPITZBERG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPITZBERG
Provider First Name:
JACK
Provider Middle Name:
W
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:
1619976966
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8440 WALNUT HILL LN STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75231-3879
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-369-3613
Provider Business Mailing Address Fax Number:
214-369-6042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8440 WALNUT HILL LN STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75231-3879
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-369-3613
Provider Business Practice Location Address Fax Number:
214-369-6042
Provider Enumeration Date:
07/19/2005

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:  E4085 , 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: 116656301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110044853 . This is a "RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 060036467 . This is a "RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 116656303 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00044329 . This is a "RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 80A132 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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