1538113592 NPI number — DR. JEFFREY A FEARON M.D.,F.A.C.S.

Table of content: DR. JEFFREY A FEARON M.D.,F.A.C.S. (NPI 1538113592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538113592 NPI number — DR. JEFFREY A FEARON M.D.,F.A.C.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FEARON
Provider First Name:
JEFFREY
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.,F.A.C.S.
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:
1538113592
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7777 FOREST LN STE C700
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75230-2518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-566-6464
Provider Business Mailing Address Fax Number:
972-566-6279

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7777 FOREST LN STE C700
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75230-2518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-566-6464
Provider Business Practice Location Address Fax Number:
972-566-6279
Provider Enumeration Date:
05/22/2006

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: 2086S0122X , with the licence number:  H8638 , 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: 000E1668 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10010045 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00X682 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 118956501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1921297 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 208847509 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 91863803 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0722264 . This is a "IOWA MEDICAID" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 8F5212 . This is a "MEDICARE INDIVIDUAL PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 118956502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3858 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5542707 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 093725201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 86J892 . This is a "BC/BS PROVIDER ID NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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