Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207X00000X | Orthopaedic Surgeon | K3615 | TX |
N | 207XS0106X | Orthopaedic Hand Surgeon | K3615 | TX |
N | 207XS0114X | Adult Reconstructive Orthopaedic Surgeon | K3615 | TX |
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | K3615 | TX |
N | 207XX0801X | Orthopaedic Trauma Surgeon | K3615 | TX |
NPI | 1083604458 |
---|---|
Provider Name | Virgil B Medlock |
First Address | Dallas, TX 75265-0500 |
Second Address | Dallas, TX 75246-1615 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/10/2005 |
Last Update Date | 28/09/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
152255901 | (05) | TX |
152255902 | (05) | TX |
152255903 | (05) | TX |
8A5019 | BCBS (01) | TX |
H21612 | (02) |