1760492565 NPI number — DR. THOMAS FITZPATRICK M.D.

Table of content: DR. THOMAS FITZPATRICK M.D. (NPI 1760492565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760492565 NPI number — DR. THOMAS FITZPATRICK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZPATRICK
Provider First Name:
THOMAS
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
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:
1760492565
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 847522
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:
75284-7522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-531-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2026 S JACKSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75766-5822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-541-4500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/08/2006

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: 207X00000X , with the licence number:  054715 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: P2987 , 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: 495265666A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8DF184 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 751976930005 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 302573601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01073140 . This is a "RAIL ROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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