Basic Information
| Provider Information | |||||||||
| NPI: | 1770672586 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VALIS | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99406 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176052833 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6316 PRECINCT LINE RD | ||||||||
| Address2: | |||||||||
| City: | HURST | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760542766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176052500 | ||||||||
| FaxNumber: | 8176052983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 04/01/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | H2867 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0050NC | 01 | TX | BCBSTX GRP PIN | OTHER | 1912978891 | 01 | GRP NPI NUMBER | OTHER | 10028901 | 01 | TX | AMERIGROUP PIN | OTHER | 170994101 | 05 | TX | MEDICAID | 137544613 | 05 | TX | MEDICAID | 8B7944 | 01 | TX | BCBSTX IND PIN | OTHER | 8V0286 | 01 | TX | BCBS | OTHER | 125966102 | 01 | TX | FIRSTCARE PIN | OTHER | 163314101 | 05 | TX | MEDICAID | 080626701 | 05 | TX | MEDICAID | 137544611 | 05 | TX | MEDICAID | 137544612 | 05 | TX | MEDICAID | 4140263 | 01 | TX | AETN APIN | OTHER | 101503 | 01 | TX | SUPERIOR PIN | OTHER | 54148 | 01 | TX | FIRSTHEALTH PIN | OTHER |