1386833374 NPI number — DALLAS PEDIATRICS & INFECTIOUS DISEASE ASSOCIATES

Table of content: (NPI 1386833374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386833374 NPI number — DALLAS PEDIATRICS & INFECTIOUS DISEASE ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DALLAS PEDIATRICS & INFECTIOUS DISEASE ASSOCIATES
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:
1386833374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1120 S MAIN ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
GRAPEVINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76051-5543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-416-5554
Provider Business Mailing Address Fax Number:
817-416-5556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
GRAPEVINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76051-5543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-416-5554
Provider Business Practice Location Address Fax Number:
817-416-5556
Provider Enumeration Date:
10/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GHAFFAR
Authorized Official First Name:
FARYAL
Authorized Official Middle Name:
ABDUL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
817-416-5554

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  K9784 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2080P0208X , with the licence number: K9784 , 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: 175070501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0088MQ . This is a "BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 175070502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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