Basic Information
Provider Information | |||||||||
NPI: | 1750327862 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAUK | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | H | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4637 MARBELLA CIR | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761261927 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8177336566 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 950 W MAGNOLIA AVE | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761044501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8173365060 | ||||||||
FaxNumber: | 8173361744 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2006 | ||||||||
LastUpdateDate: | 02/16/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | E2284 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 10028773 | 01 |   | AMERIGROUP | OTHER | 118141401 | 05 | TX |   | MEDICAID | 1634476 | 01 |   | UNISYS LOUISIANA MEDICAID | OTHER | 4036862 | 01 |   | AETNA | OTHER | 834766 | 01 |   | BLUE CROSS BLUE SHIELD TX | OTHER | 110081715 | 01 |   | MEDICARE RAILROAD | OTHER |