1255335782 NPI number — JARRELL PAUL REYNOLDS MD

Table of content: JARRELL PAUL REYNOLDS MD (NPI 1255335782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255335782 NPI number — JARRELL PAUL REYNOLDS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REYNOLDS
Provider First Name:
JARRELL
Provider Middle Name:
PAUL
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:
1255335782
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/16/2006
NPI Reactivation Date:
03/30/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 312
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLEMAN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76834-0312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-625-3533
Provider Business Mailing Address Fax Number:
325-625-3477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 S PECOS ST
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
COLEMAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76834-4159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-625-3533
Provider Business Practice Location Address Fax Number:
325-625-3477
Provider Enumeration Date:
06/13/2005

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: 207Q00000X , with the licence number:  H0755 , 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: 138941307 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 138941312 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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