Basic Information
Provider Information | |||||||||
NPI: | 1205812898 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCNEILL | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3002 SAM HOUSTON DR | ||||||||
Address2: |   | ||||||||
City: | VICTORIA | ||||||||
State: | TX | ||||||||
PostalCode: | 779042682 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3615785730 | ||||||||
FaxNumber: | 3615780749 | ||||||||
Practice Location | |||||||||
Address1: | 3002 SAM HOUSTON DR | ||||||||
Address2: |   | ||||||||
City: | VICTORIA | ||||||||
State: | TX | ||||||||
PostalCode: | 779042682 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3615785730 | ||||||||
FaxNumber: | 3615780749 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/16/2005 | ||||||||
LastUpdateDate: | 08/14/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | K5623 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207P00000X | K5623 | TX | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 139635007 | 05 | TX |   | MEDICAID | DH0924 | 01 | TX | MEDICARE RR | OTHER | 0034ET | 01 | TX | BCBS OF TX # | OTHER | 74-2964639 | 01 | TX | TAX ID # | OTHER |