Basic Information
| Provider Information | |||||||||
| NPI: | 1285694984 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1604 14TH ST | ||||||||
| Address2: | |||||||||
| City: | BROWNWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 768015314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256465296 | ||||||||
| FaxNumber: | 3256465820 | ||||||||
| Practice Location | |||||||||
| Address1: | 1604 14TH ST | ||||||||
| Address2: | |||||||||
| City: | BROWNWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 768015314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256465296 | ||||||||
| FaxNumber: | 3256465820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2006 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G4784 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 127751908 | 05 | TX | MEDICAID | G4784 | 01 | TX | TEXAS MEDICAL LIC # | OTHER | 252944274 | 01 | BCBS # | OTHER | 11368850 | 01 | CAQH | OTHER | H08CG76301 | 01 | BCBSTX PCP | OTHER | AA3141241 | 01 | DEA | OTHER | D0060429 | 01 | TX | TX DPS | OTHER | H00061TE01 | 01 | BC PROVIDER # | OTHER |