1063491462 NPI number — DR. LAVAN R PARKER III DDS

Table of content: DR. LAVAN R PARKER III DDS (NPI 1063491462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063491462 NPI number — DR. LAVAN R PARKER III DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARKER
Provider First Name:
LAVAN
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
DDS
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:
1063491462
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6501 BLANCO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-341-7264
Provider Business Mailing Address Fax Number:
210-341-2022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6501 BLANCO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-341-7264
Provider Business Practice Location Address Fax Number:
210-341-2022
Provider Enumeration Date:
01/13/2006

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: 1223S0112X , with the licence number:  17827 , 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: 151926601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00147516 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 731009960006 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 151926608 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 151926605 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 151926607 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 838355 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 151926606 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 151926602 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 80W704 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 151926603 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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