1861682700 NPI number — WILL E CLOSE MD

Table of content: WILL E CLOSE MD (NPI 1861682700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861682700 NPI number — WILL E CLOSE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLOSE
Provider First Name:
WILL
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1861682700
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 ROSALIND REDFERN GROVER PKWY
Provider Second Line Business Mailing Address:
RADIOLOGY DEPT
Provider Business Mailing Address City Name:
MIDLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79701-5846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-221-2730
Provider Business Mailing Address Fax Number:
432-221-1075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 ROSALIND REDFERN GROVER PKWY
Provider Second Line Business Practice Location Address:
RADIOLOGY DEPT
Provider Business Practice Location Address City Name:
MIDLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79701-5846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-221-2730
Provider Business Practice Location Address Fax Number:
432-221-1075
Provider Enumeration Date:
07/26/2007

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: 2085R0202X , with the licence number:  P3870 , 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: 1077259 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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