1407060783 NPI number — DAVID MEDUNA, M.D., P.A.

Table of content: (NPI 1407060783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407060783 NPI number — DAVID MEDUNA, M.D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID MEDUNA, 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:
1407060783
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1602 ROCK PRAIRIE RD
Provider Second Line Business Mailing Address:
STE 3100
Provider Business Mailing Address City Name:
COLLEGE STATION
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77845-8306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-764-6868
Provider Business Mailing Address Fax Number:
979-694-8804

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1602 ROCK PRAIRIE RD
Provider Second Line Business Practice Location Address:
STE 3100
Provider Business Practice Location Address City Name:
COLLEGE STATION
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77845-8306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-764-6868
Provider Business Practice Location Address Fax Number:
979-694-8804
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MEDUNA
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
979-764-6868

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1275726853 . This is a "COLLEGE STATION CLINIC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 187842302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1821185299 . This is a "BVCAA AGENCY" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0026PV . This is a "BLUE CROSS BLUE SHIELD OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 184841802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 187842301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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