Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | E3137 | TX |
NPI | 1003858010 |
---|---|
Provider Name | John Q.a. Webb JR. |
First Address | Beaumont, TX 77708-5320 |
Second Address | Beaumont, TX 77708-5320 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2006 |
Last Update Date | 30/01/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8AM940 | BLUE CROSS BLUE SHIELD (01) | TX |
D69235 | (02) | TX |