1780656165 NPI number — DR. LON ALAN FRY D.O.

Table of content: SARAH CRUZ SLP (NPI 1922430651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780656165 NPI number — DR. LON ALAN FRY D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRY
Provider First Name:
LON
Provider Middle Name:
ALAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1780656165
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
203 TOPHILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78209-3443
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-824-6986
Provider Business Mailing Address Fax Number:
210-292-7986

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BROOKE ARMY MEDICAL CENTER
Provider Second Line Business Practice Location Address:
3551 ROGER BROOKE DRIVE
Provider Business Practice Location Address City Name:
JBSA FORT SAM HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78234-4504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-916-6705
Provider Business Practice Location Address Fax Number:
210-916-8712
Provider Enumeration Date:
02/01/2006

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: 207LP3000X , with the licence number:  K1196 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: K1196 , 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)