1710940564 NPI number — DR. DEANNA J POWELL O.D.

Table of content: DR. DEANNA J POWELL O.D. (NPI 1710940564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710940564 NPI number — DR. DEANNA J POWELL O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POWELL
Provider First Name:
DEANNA
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

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:
1710940564
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12934 GRANDSTAND WAY
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:
76244-7280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-584-2230
Provider Business Mailing Address Fax Number:
913-254-9613

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1228 US 377
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76262-7280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-584-2230
Provider Business Practice Location Address Fax Number:
913-254-9613
Provider Enumeration Date:
04/11/2006

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: 152W00000X , with the licence number:  8320T , 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: 203384798 . This is a "FREEDOM NETWORK" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 20338479866220A002 . This is a "TRICARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 31795041 . This is a "BC/BS OF KC" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 7038483 . This is a "AETNA" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 20-3384798 . This is a "UHC" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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