NPI age
19 years
Enumerated 2006-11-01
Across 4038 active specialist providers in Texas.
| Type | Value | Notes |
|---|---|---|
| 05 (TX) | 089752201 | |
| 01 (TX) | EO111 | TEXAS STATE MEDICAL LICEN |
| 01 (TX) | W0017106 | DPS LICENSE |
Part of a multi-provider practice. 2 other active providers share this practice address in NPPES.
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