Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | N3619 | TX |
NPI | 1003870718 |
---|---|
Provider Name | Robert J Dimeff |
First Address | Dallas, TX 75231-4418 |
Second Address | Dallas, TX 75231-4313 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/04/2006 |
Last Update Date | 17/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8HU421 | BCBS (01) | TX |
E18507 | (02) | OH |