1831264274 NPI number — DR. DIANE MARILEE GARD PHD

Table of content: DR. DIANE MARILEE GARD PHD (NPI 1831264274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831264274 NPI number — DR. DIANE MARILEE GARD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARD
Provider First Name:
DIANE
Provider Middle Name:
MARILEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1831264274
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2107
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MABANK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75147-5017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-368-2299
Provider Business Mailing Address Fax Number:
903-489-0111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
122 S GUN BARREL LN
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
GUN BARREL CITY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75156-9403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-887-0697
Provider Business Practice Location Address Fax Number:
903-887-0698
Provider Enumeration Date:
11/21/2006

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: 103T00000X , with the licence number:  2264 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 33829 , 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: 614301 . This is a "MEDICARE B" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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