1982185815 NPI number — MRS. DESIREE YVONNE VANDER MEULEN COTA

Table of content: MRS. DESIREE YVONNE VANDER MEULEN COTA (NPI 1982185815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982185815 NPI number — MRS. DESIREE YVONNE VANDER MEULEN COTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDER MEULEN
Provider First Name:
DESIREE
Provider Middle Name:
YVONNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
COTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CATHEY
Provider Other First Name:
DESIREE
Provider Other Middle Name:
YVONNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1982185815
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9913 DUBLIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79765-1484
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-361-4048
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5001 OFFICE PARK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79762-4843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-362-1800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/28/2018

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: 224Z00000X , with the licence number:  214166 , 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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