1356521892 NPI number — ROGER J. WOLCOTT, M.D., P.A.

Table of content: (NPI 1356521892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356521892 NPI number — ROGER J. WOLCOTT, M.D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROGER J. WOLCOTT, M.D., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1356521892
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5902 66TH ST UNIT B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79424-5933
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-797-2139
Provider Business Mailing Address Fax Number:
806-797-3105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5902 66TH ST UNIT B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79424-5933
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-797-2139
Provider Business Practice Location Address Fax Number:
806-797-3105
Provider Enumeration Date:
11/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BEYER
Authorized Official First Name:
JANET
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
806-797-2139

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  J4620 , 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: 110687404 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 172052601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00028AA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com