Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | M1746 | TX |
Y | 207PE0004X | Emergency Medical Services | M1746 | TX |
NPI | 1083679799 |
---|---|
Provider Name | Mr. Dennis R Haslam JR. |
First Address | Keene, TX 76059 |
Second Address | Fort Worth, TX 76134 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/04/2006 |
Last Update Date | 21/06/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
176681801 | (05) | TX |
I21117 | (02) | TX |