1932319894 NPI number — DR. THERON CLAY MOCK JR. M. D.

Table of content: DR. THERON CLAY MOCK JR. M. D. (NPI 1932319894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932319894 NPI number — DR. THERON CLAY MOCK JR. M. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOCK
Provider First Name:
THERON
Provider Middle Name:
CLAY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
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:
1932319894
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
465 GYPSY LN
Provider Second Line Business Mailing Address:
APT 312
Provider Business Mailing Address City Name:
YOUNGSTOWN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44504-1361
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-746-5111
Provider Business Mailing Address Fax Number:
330-746-5111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
465 GYPSY LN
Provider Second Line Business Practice Location Address:
APT 312
Provider Business Practice Location Address City Name:
YOUNGSTOWN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44504-1361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-746-5111
Provider Business Practice Location Address Fax Number:
330-746-5111
Provider Enumeration Date:
05/22/2007

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: 208600000X , with the licence number:  35-04-5230 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0976412 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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