1649592205 NPI number — JOHN ALLEN VAN WAGONER M.D. P.A.

Table of content: (NPI 1649592205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649592205 NPI number — JOHN ALLEN VAN WAGONER M.D. P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN ALLEN VAN WAGONER M.D. P.A.
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:
1649592205
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6101 WINDCOM COURT
Provider Second Line Business Mailing Address:
STE 400
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75093-7817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-398-3500
Provider Business Mailing Address Fax Number:
972-398-3512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3105 COLORADO BLVD.
Provider Second Line Business Practice Location Address:
STE 150
Provider Business Practice Location Address City Name:
DENTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-398-3500
Provider Business Practice Location Address Fax Number:
972-398-3512
Provider Enumeration Date:
02/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
VAN WAGONER
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
972-398-3500

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X , with the licence number:  K8854 , 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)





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