Basic Information
Provider Information | |||||||||
NPI: | 1932115136 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOZDIC | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | LEROY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | II | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1326 | ||||||||
Address2: |   | ||||||||
City: | MARSHALL | ||||||||
State: | TX | ||||||||
PostalCode: | 756711326 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9039273782 | ||||||||
FaxNumber: | 9039271764 | ||||||||
Practice Location | |||||||||
Address1: | 1011 SOUTH WILLIAM | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | TX | ||||||||
PostalCode: | 75551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9037962868 | ||||||||
FaxNumber: | 9037960826 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2006 | ||||||||
LastUpdateDate: | 07/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | J8587 | TX | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 080108632 | 01 |   | MEDICARE RR | OTHER | 117838 | 01 |   | CHIPS | OTHER | 83610F | 01 | TX | BCBS | OTHER | 116919503 | 05 | TX |   | MEDICAID | 97677 | 01 | AR | BCBS | OTHER | A012 | 01 |   | CHAMPUS | OTHER |