Basic Information
Provider Information | |||||||||
NPI: | 1831393412 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARCELLS | ||||||||
FirstName: | JEREMY | ||||||||
MiddleName: | PATRICK | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 961205 | ||||||||
Address2: |   | ||||||||
City: | FORT WORTH | ||||||||
State: | TX | ||||||||
PostalCode: | 761611205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8177408400 | ||||||||
FaxNumber: | 8173783699 | ||||||||
Practice Location | |||||||||
Address1: | 2975 E BROAD ST STE 200 | ||||||||
Address2: |   | ||||||||
City: | MANSFIELD | ||||||||
State: | TX | ||||||||
PostalCode: | 760639147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6825188619 | ||||||||
FaxNumber: | 6825188195 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2007 | ||||||||
LastUpdateDate: | 11/04/2016 | ||||||||
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 | 208600000X | 6847 | NE | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | P7967 | TX | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 332557301 | 05 | TX |   | MEDICAID | 6847 | 01 | NE | TEMPORARY EDUCATION PERMIT | OTHER | 3870853755 | 01 |   | MYUTMB 3870853755-COMMERCIAL NUMBER | OTHER | P7967 | 01 | TX | MEDICAL LICENSE | OTHER |