Basic Information
Provider Information
NPI: 1033559778
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JONES
FirstName: RYAN
MiddleName: EDWARD
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1400 HI LINE DR
Address2: #2209
City: DALLAS
State: TX
PostalCode: 752073435
CountryCode: US
TelephoneNumber: 4693374091
FaxNumber:  
Practice Location
Address1: 1301 W 7TH ST
Address2: STE 121
City: FORT WORTH
State: TX
PostalCode: 761022651
CountryCode: US
TelephoneNumber: 8173480425
FaxNumber: 8173480455
Other Information
ProviderEnumerationDate: 06/26/2013
LastUpdateDate: 08/16/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000XQ4778TXY Allopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


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