Basic Information
| Provider Information | |||||||||
| NPI: | 1417046418 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | DOREATHA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | POWELL | ||||||||
| OtherFirstName: | D | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9300 COIT RD | ||||||||
| Address2: | #228 | ||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750254481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143877899 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2920 NORTH STEMMONS | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146302331 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M5447 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4432 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.