1831704162 NPI number — DR. DERRECKA M BOYKIN PHD

Table of content: DR. DERRECKA M BOYKIN PHD (NPI 1831704162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831704162 NPI number — DR. DERRECKA M BOYKIN PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOYKIN
Provider First Name:
DERRECKA
Provider Middle Name:
M
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:
BUTLER
Provider Other First Name:
DERRECKA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1831704162
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2002 HOLCOMBE BLVD # 152
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77030-4211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2002 HOLCOMBE BLVD # 152
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77030-4211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-791-1414
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2020

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: 103TC0700X , with the licence number:  38451 , 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)