Basic Information
| Provider Information | |||||||||
| NPI: | 1295870657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACOMBER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RNFA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99371 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851855 | ||||||||
| FaxNumber: | 6828857347 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 COOPER ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828852500 | ||||||||
| FaxNumber: | 6828852510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 04/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | 589407 | TX | Y | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
ID Information
| ID | Type | State | Issuer | Description | 10064792 | 01 | TX | AMGP PIN | OTHER | 7215895 | 01 | TX | AETNA PIN | OTHER | 1750369203 | 01 | GRP NPI NUMBER | OTHER | 152265100 | 01 | TX | FIRSTCARE PIN | OTHER | 00U87Z | 01 | TX | BCBSTX GRP PIN | OTHER | 178303701 | 05 | TX | MEDICAID | 8N8074 | 01 | TX | BCBSTX IND PIN | OTHER | 9447385 | 01 | TX | PHCS PIN | OTHER |