1265561005 NPI number — LISETTE C DOMITEAUX PH. D.

Table of content: LISETTE C DOMITEAUX PH. D. (NPI 1265561005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265561005 NPI number — LISETTE C DOMITEAUX PH. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMITEAUX
Provider First Name:
LISETTE
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH. D.
Provider Gender Code:
F

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:
1265561005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5925 FOREST LANE
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75230-8805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-363-0277
Provider Business Mailing Address Fax Number:
214-352-5388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5925 FOREST LANE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75230-8805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-363-0277
Provider Business Practice Location Address Fax Number:
214-352-5388
Provider Enumeration Date:
03/05/2007

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: 101YM0800X , with the licence number:  8717 , 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: 752231883 . This is a "FEDERAL TAX ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com