Basic Information
Provider Information | |||||||||
NPI: | 1609066620 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHYSICIANS OF KING'S DAUGHTERS, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KING'S DAUGHTERS CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1905 SW H K DODGEN LOOP | ||||||||
Address2: |   | ||||||||
City: | TEMPLE | ||||||||
State: | TX | ||||||||
PostalCode: | 765021814 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2542982682 | ||||||||
FaxNumber: | 2547787197 | ||||||||
Practice Location | |||||||||
Address1: | 1905 SW H K DODGEN LOOP | ||||||||
Address2: |   | ||||||||
City: | TEMPLE | ||||||||
State: | TX | ||||||||
PostalCode: | 765021814 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2542982682 | ||||||||
FaxNumber: | 2547787197 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2007 | ||||||||
LastUpdateDate: | 07/21/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCAFFREY | ||||||||
AuthorizedOfficialFirstName: | EDWARD | ||||||||
AuthorizedOfficialMiddleName: | T. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT BOARD OF DIRECTORS | ||||||||
AuthorizedOfficialTelephone: | 2542982682 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335V00000X | 0584 | TX | Y |   | Suppliers | Portable X-Ray Supplier |   |
ID Information
ID | Type | State | Issuer | Description | 181326301 | 05 | TX |   | MEDICAID | 1316933401 | 01 | TX | PHYSICIAN NPI NUMBER | OTHER |