1396789491 NPI number — DEWITT MEDICAL DISTRICT

Table of content: (NPI 1396789491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396789491 NPI number — DEWITT MEDICAL DISTRICT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEWITT MEDICAL DISTRICT
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:
6
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:
1396789491
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 MAPLE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LULING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-875-5219
Provider Business Mailing Address Fax Number:
830-875-2919

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 MAPLE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LULING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-875-5219
Provider Business Practice Location Address Fax Number:
830-875-2919
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ALEXANDER
Authorized Official First Name:
ALMA
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED REPRESENTATIVE
Authorized Official Telephone Number:
361-275-0504

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  115095 , 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: 001030462 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com