Basic Information
| Provider Information | |||||||||
| NPI: | 1629056908 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATRICK | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 910 E HOUSTON ST | ||||||||
| Address2: | STE 330 | ||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757028369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035257995 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 10/13/2014 | ||||||||
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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 | 207T00000X | 44797 | MN | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | N1052 | TX | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 689448800 | 05 | MN | MEDICAID | 8BC076 | 01 | TX | BCBS OF TEXAS | OTHER |