Basic Information
Provider Information | |||||||||
NPI: | 1801100342 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | YAGER | ||||||||
FirstName: | MARIANA | ||||||||
MiddleName: | BRAGA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RESENDE | ||||||||
OtherFirstName: | MARIANA | ||||||||
OtherMiddleName: | BRAGA | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1420 VICEROY DR | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752352208 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2143582300 | ||||||||
FaxNumber: | 2145796966 | ||||||||
Practice Location | |||||||||
Address1: | 1250 8TH AVE STE 500 | ||||||||
Address2: |   | ||||||||
City: | FT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761044145 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2143582300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2010 | ||||||||
LastUpdateDate: | 02/27/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | P4131 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 3080731-02 | 05 | TX |   | MEDICAID |