Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | M2606 | TX |
NPI | 1003853722 |
---|---|
Provider Name | Crisanto G Dimafelix |
First Address | Forney, TX 75126 |
Second Address | Addison, TX 75001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2006 |
Last Update Date | 26/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8L22781 | (02) | TX |
I48269 | (02) | TX |