Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0210X | Pediatric Nephrologist | D0003 | TX |
NPI | 1700978418 |
---|---|
Provider Name | Luther B. Travis |
First Address | Galveston, TX 77555-1022 |
Second Address | Galveston, TX 77555-1022 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C22758 | (02) | TX |