Basic Information
Provider Information | |||||||||
NPI: | 1720031370 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UROLOGY CLINICS OF NORTH TEXAS, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3600 GASTON AVE | ||||||||
Address2: | SUITE 1205 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752461800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146928262 | ||||||||
FaxNumber: | 2146964190 | ||||||||
Practice Location | |||||||||
Address1: | 8230 WALNUT HILL LN | ||||||||
Address2: | SUITE 700 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752314482 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146911902 | ||||||||
FaxNumber: | 2149871845 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2006 | ||||||||
LastUpdateDate: | 03/07/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILSON | ||||||||
AuthorizedOfficialFirstName: | JERRI | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2146911902 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | K3232 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2088P0231X | G9345 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 208800000X | M0918 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 119844205 | 05 | TX |   | MEDICAID | 119844204 | 05 | TX |   | MEDICAID | CI6342 | 01 | TX | RR MEDICARE GROUP | OTHER | 0036DE | 01 |   | BCBS GROUP | OTHER | 119844203 | 05 | TX |   | MEDICAID |