1174565279 NPI number — JOHN WINNINGHAM DO

Table of content: JOHN WINNINGHAM DO (NPI 1174565279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174565279 NPI number — JOHN WINNINGHAM DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WINNINGHAM
Provider First Name:
JOHN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174565279
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8549
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76124-0549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-451-4208
Provider Business Mailing Address Fax Number:
817-496-5151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4301 WILSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWTON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73503-4472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-284-5566
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  6801 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 173122603 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0097MP . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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