1639317431 NPI number — NORTH DALLAS RETINA, PA

Table of content: (NPI 1639317431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639317431 NPI number — NORTH DALLAS RETINA, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH DALLAS RETINA, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1639317431
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 671541
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:
75267-1541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-553-9524
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10740 N CENTRAL EXPY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75231-2162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-361-6700
Provider Business Practice Location Address Fax Number:
214-361-6701
Provider Enumeration Date:
02/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
JOST
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
214-553-9524

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  F6807 , 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)





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