1578890216 NPI number — DR. MANDY JO POCKRUS MD

Table of content: DR. MANDY JO POCKRUS MD (NPI 1578890216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578890216 NPI number — DR. MANDY JO POCKRUS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POCKRUS
Provider First Name:
MANDY
Provider Middle Name:
JO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POCKRUS
Provider Other First Name:
MANDY
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1578890216
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 844658
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:
75284-4658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-724-8800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4035 STATE HIGHWAY 6 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLEGE STATION
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77845-8963
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-207-6400
Provider Business Practice Location Address Fax Number:
979-207-6401
Provider Enumeration Date:
11/16/2009

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:  N7132 , 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: 22020201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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