1942257746 NPI number — LOFTON N MISICK MD

Table of content: LOFTON N MISICK MD (NPI 1942257746)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942257746 NPI number — LOFTON N MISICK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MISICK
Provider First Name:
LOFTON
Provider Middle Name:
N
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:
1942257746
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
ID#1177
Provider Second Line Business Mailing Address:
PO BOX 659506
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78265-9506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-761-8610
Provider Business Mailing Address Fax Number:
361-761-8611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
819 AYERS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORPUS CHRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78404-1914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-761-8610
Provider Business Practice Location Address Fax Number:
361-761-8611
Provider Enumeration Date:
05/27/2006

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: 208G00000X , with the licence number:  Q7428 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X , with the licence number: Q7428 , 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: 2029665 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 364986503 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102308600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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