1477675254 NPI number — DUSTIN L. REID, MD PA

Table of content: (NPI 1477675254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477675254 NPI number — DUSTIN L. REID, MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DUSTIN L. REID, MD PA
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:
1477675254
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 W. 38TH ST.
Provider Second Line Business Mailing Address:
SUITE 401
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78705-1162
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-371-8817
Provider Business Mailing Address Fax Number:
512-371-8819

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 W. 38TH ST.,
Provider Second Line Business Practice Location Address:
SUITE 401
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78705-1162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-371-8817
Provider Business Practice Location Address Fax Number:
512-371-8819
Provider Enumeration Date:
04/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
REID
Authorized Official First Name:
DUSTIN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
512-371-8817

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  M1314 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0122X , with the licence number: M1314 , 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: 1093782062 . This is a "INDIVIDUAL NPI DR. DUSTIN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 176043101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1124048343 . This is a "NPI DR. ASHLEY GORDON" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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