1932128501 NPI number — DR. SARA RUTH FAVORITE PH.D

Table of content: DR. SARA RUTH FAVORITE PH.D (NPI 1932128501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932128501 NPI number — DR. SARA RUTH FAVORITE PH.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAVORITE
Provider First Name:
SARA
Provider Middle Name:
RUTH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STEVENSON
Provider Other First Name:
SARA
Provider Other Middle Name:
RUTH
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1932128501
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5625 BROADWAY AVE
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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-264-5122
Provider Business Mailing Address Fax Number:
210-822-7321

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5625 BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-264-5122
Provider Business Practice Location Address Fax Number:
210-822-7321
Provider Enumeration Date:
07/18/2006

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: 103T00000X , with the licence number:  32427 , 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: 1690638-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".