1912057183 NPI number — THOMAS WALTER WALKIEWICZ MD

Table of content: THOMAS WALTER WALKIEWICZ MD (NPI 1912057183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912057183 NPI number — THOMAS WALTER WALKIEWICZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALKIEWICZ
Provider First Name:
THOMAS
Provider Middle Name:
WALTER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1912057183
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
815 PENNSYLVANIA AVE
Provider Second Line Business Mailing Address:
STE 510
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104-2224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-321-0937
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8440 WALNUT HILL LN
Provider Second Line Business Practice Location Address:
STE 510
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75231-3833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-805-6711
Provider Business Practice Location Address Fax Number:
214-345-5543
Provider Enumeration Date:
01/11/2007

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: 2085N0700X , with the licence number:  N6761 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: N6761 , 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: 145J0 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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