Basic Information
| Provider Information | |||||||||
| NPI: | 1851303226 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VERNON & WALDREP OB-GYN ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7777 FOREST LN | ||||||||
| Address2: | BLDG D-570 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725664660 | ||||||||
| FaxNumber: | 9725666413 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 FOREST LN | ||||||||
| Address2: | BLDG D-570 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725664660 | ||||||||
| FaxNumber: | 9725666413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 02/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | VERNON | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | DAWSON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9725664660 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 809549-03 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 085504101 | 05 | TX | MEDICAID |