Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208D00000X | General Practice Physician | H2496 | TX |
NPI | 1003161530 |
---|---|
Provider Name | Thomas Joe |
First Address | Irving, TX 75062-6513 |
Second Address | Irving, TX 75062-6513 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2012 |
Last Update Date | 06/08/2012 |