Basic Information
Provider Information | |||||||||
NPI: | 1407821366 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAYNE | ||||||||
FirstName: | GERALD | ||||||||
MiddleName: | GENE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 100186 | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761850186 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8177317771 | ||||||||
FaxNumber: | 8177317774 | ||||||||
Practice Location | |||||||||
Address1: | 1600 W COLLEGE ST | ||||||||
Address2: | STE 210 | ||||||||
City: | GRAPEVINE | ||||||||
State: | TX | ||||||||
PostalCode: | 760513580 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8174810111 | ||||||||
FaxNumber: | 8174810112 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2006 | ||||||||
LastUpdateDate: | 02/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | G3678 | TX | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
ID | Type | State | Issuer | Description | 135806115 | 05 | TX |   | MEDICAID | 74999 | 01 | TX | AMERIGROUP | OTHER | 135806110 | 05 | TX |   | MEDICAID | 4292523 | 01 | TX | AETNA | OTHER | 135806109 | 05 | TX |   | MEDICAID | 8H3361 | 01 | TX | BCBS | OTHER |