1902007560 NPI number — DIANE G VANMAELE DO

Table of content: DIANE G VANMAELE DO (NPI 1902007560)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902007560 NPI number — DIANE G VANMAELE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANMAELE
Provider First Name:
DIANE
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

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:
1902007560
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 99371
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76199-0371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
682-885-1855
Provider Business Mailing Address Fax Number:
682-885-7347

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2530 SCRIPTURE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76201-4317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-898-1477
Provider Business Practice Location Address Fax Number:
940-382-4091
Provider Enumeration Date:
05/30/2007

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: 208000000X , with the licence number:  M6928 , 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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