Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207K00000X | Allergist & Immunologist | B9692 | TX |
NPI | 1073629929 |
---|---|
Provider Name | Dr. Theophilus Shickel Painter JR. |
First Address | Austin, TX 78705 |
Second Address | Austin, TX 78705 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0004CN | BLUE CROSS (01) | TX |
C20134 | (02) | |
PO82G6118 | (05) | TX |