1477549749 NPI number — MR. KENNETH GORDON GOLDABER MD

Table of content: MR. KENNETH GORDON GOLDABER MD (NPI 1477549749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477549749 NPI number — MR. KENNETH GORDON GOLDABER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDABER
Provider First Name:
KENNETH
Provider Middle Name:
GORDON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1477549749
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 W MAYFIELD RD
Provider Second Line Business Mailing Address:
SUITE 304
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76014-2083
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-467-1010
Provider Business Mailing Address Fax Number:
817-419-2626

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 W MAYFIELD RD
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76014-2083
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-467-1010
Provider Business Practice Location Address Fax Number:
817-419-2626
Provider Enumeration Date:
09/22/2005

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: 207VM0101X , with the licence number:  H3815 , 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: 161496801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 27KH . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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