Basic Information
| Provider Information | |||||||||
| NPI: | 1508067760 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIRDWELL | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | PAULINE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EMMETT | ||||||||
| OtherFirstName: | KATRINA | ||||||||
| OtherMiddleName: | PAULINE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9722340813 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 W COLORADO BLVD | ||||||||
| Address2: | PAV II, SUITE 532 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752082363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149438605 | ||||||||
| FaxNumber: | 2149468339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 12/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | P0580 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 2086X0206X | P0580 | TX | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 306166505 | 05 | TX | MEDICAID | 306166504 | 05 | TX | MEDICAID | 306166506 | 05 | TX | MEDICAID |