1790083111 NPI number — LEON R. BRILL, D.P.M., F.A.C.F.A.S., P.A.

Table of content: (NPI 1790083111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790083111 NPI number — LEON R. BRILL, D.P.M., F.A.C.F.A.S., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEON R. BRILL, D.P.M., F.A.C.F.A.S., P.A.
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:
NORTH TEXAS PODIATRIC MEDICINE AND SURGERY
Provider Other Organization Name Type Code:
3
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:
1790083111
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5481 BLAIR RD
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:
75231-4101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-369-7400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5481 BLAIR RD
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:
75231-4101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-369-7400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/09/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BRILL
Authorized Official First Name:
LEON
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
214-369-7400

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  0628 , 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: 092803802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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