1114092871 NPI number — DR. EVELYN VIRGINIA SHEARER

Table of content: DR. EVELYN VIRGINIA SHEARER (NPI 1114092871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114092871 NPI number — DR. EVELYN VIRGINIA SHEARER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHEARER
Provider First Name:
EVELYN
Provider Middle Name:
VIRGINIA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHEARER-POOR
Provider Other First Name:
EVELYN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114092871
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 GASTON AVE
Provider Second Line Business Mailing Address:
WADLEY TOWER STE 962
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75246-1800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-818-8386
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 MARIE CURIE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75042-5706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-818-8386
Provider Business Practice Location Address Fax Number:
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: 207RC0200X , with the licence number:  J3218 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RP1001X , with the licence number: J3218 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: J3218 . This is a "TEXAS STATE PERMIT" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: MD28144 . This is a "OREGON STATE PERMIT" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 1285157-07 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: MD2008-0719 . This is a "NEW MEXICO STATE PERMIT" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: MD00046604 . This is a "WASHINGTON STATE PERMIT" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: T0083311 . This is a "DPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 128515702 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33561 . This is a "NORTH CAROLINA STATE PERMIT" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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