Basic Information
| Provider Information | |||||||||
| NPI: | 1891751749 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH TEXAS INFECTIOUS DISEASES CONSULTANTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 411 N WASHINGTON LB12 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752461713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148232533 | ||||||||
| FaxNumber: | 2148248679 | ||||||||
| Practice Location | |||||||||
| Address1: | 3409 WORTH ST | ||||||||
| Address2: | SUITE 710 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752462029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148232533 | ||||||||
| FaxNumber: | 2148248679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 04/16/2013 | ||||||||
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| AuthorizedOfficialLastName: | AARON | ||||||||
| AuthorizedOfficialFirstName: | SANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2142474116 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 082942601 | 05 | TX | MEDICAID |