1427167675 NPI number — JERRY L SPINKS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427167675 NPI number — JERRY L SPINKS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPINKS
Provider First Name:
JERRY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1427167675
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
410 GASLIGHT BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUFKIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75904-3195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-639-2338
Provider Business Mailing Address Fax Number:
936-639-2980

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 GASLIGHT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUFKIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75904-3195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-639-2338
Provider Business Practice Location Address Fax Number:
936-639-2980
Provider Enumeration Date:
08/30/2006

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: 207Q00000X , with the licence number:  E1137 , 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: E1137 . This is a "LIC NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: AJ05 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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