Basic Information
Provider Information | |||||||||
NPI: | 1114910379 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FRY | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | K | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1908 | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 754031908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9034543025 | ||||||||
FaxNumber: | 9034501408 | ||||||||
Practice Location | |||||||||
Address1: | 4311 WESLEY ST | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 754015639 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9034554458 | ||||||||
FaxNumber: | 9034551604 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2005 | ||||||||
LastUpdateDate: | 07/08/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | J2568 | TX | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 14506 | NE | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 130762108 | 05 | TX |   | MEDICAID | 401696YK7L | 01 | TX | MEDICARE PTAN | OTHER |