1538172267 NPI number — JAMES RANDALL GLASS O.D.

Table of content: KELSEY SMITH (NPI 1336862051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538172267 NPI number — JAMES RANDALL GLASS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLASS
Provider First Name:
JAMES
Provider Middle Name:
RANDALL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1538172267
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6986
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75505-6986
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-794-3711
Provider Business Mailing Address Fax Number:
903-794-3713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4224 TEXAS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503-3013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-794-3711
Provider Business Practice Location Address Fax Number:
903-794-3713
Provider Enumeration Date:
08/14/2006

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: 152W00000X , with the licence number:  6891T , 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: 49979 . This is a "AR BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 6891T . This is a "STATE LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1538172267 . This is a "NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 81614Q . This is a "TX BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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