1619937802 NPI number — JOHN G UNDERWOOD II M.D.

Table of content: JOHN G UNDERWOOD II M.D. (NPI 1619937802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619937802 NPI number — JOHN G UNDERWOOD II M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UNDERWOOD
Provider First Name:
JOHN
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
II
Provider Credential Text:
M.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:
1619937802
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
919 HIDDEN RDG
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75038-3813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-282-2711
Provider Business Mailing Address Fax Number:
469-282-0996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9091 ELLERBE RD
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71106-6738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-681-1630
Provider Business Practice Location Address Fax Number:
318-681-1632
Provider Enumeration Date:
03/23/2006

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: 207R00000X , with the licence number:  L03841 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1300675 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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