Basic Information
| Provider Information | |||||||||
| NPI: | 1225002850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVERETT | ||||||||
| FirstName: | HAROLD | ||||||||
| MiddleName: | U | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 706 TURTLE CREEK DR | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757011833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035953942 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 08/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | J6424 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 370009031 | 01 | TX | MEDICARE RAILROAD | OTHER | EV082Z310 | 01 | TX | BCBS | OTHER | 135158705 | 05 | TX | MEDICAID | 135158710 | 05 | TX | MEDICAID | 135158711 | 05 | TX | MEDICAID | 5598227 | 01 | TX | AETNA | OTHER | TIN PLUS SUFFIX 027 | 01 | TX | TRICARE | OTHER | 123073 | 01 | TX | CHIPS | OTHER | 135158712 | 05 | TX | MEDICAID | 018024201 | 01 | TX | EPSDT | OTHER |