Basic Information
| Provider Information | |||||||||
| NPI: | 1790930899 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIGGINBOTHAM | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12221 MERIT DRIVE | ||||||||
| Address2: | SUITE 1500 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142171900 | ||||||||
| FaxNumber: | 9406277597 | ||||||||
| Practice Location | |||||||||
| Address1: | 12221 MERIT DRIVE | ||||||||
| Address2: | SUITE 1500 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142171900 | ||||||||
| FaxNumber: | 9406277597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2008 | ||||||||
| LastUpdateDate: | 06/27/2014 | ||||||||
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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 | 207Q00000X | N4470 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 282187801 | 05 | TX | MEDICAID |