1639170194 NPI number — PAUL RICHARD GARDIAL M.D.

Table of content: PAUL RICHARD GARDIAL M.D. (NPI 1639170194)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639170194 NPI number — PAUL RICHARD GARDIAL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDIAL
Provider First Name:
PAUL
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1639170194
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5002 COWHORN CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75503-9766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-614-3000
Provider Business Mailing Address Fax Number:
903-614-3525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1408 COLLEGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503-3534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-794-0515
Provider Business Practice Location Address Fax Number:
903-793-8000
Provider Enumeration Date:
08/09/2005

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:  E3062 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: M7986 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 146876001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8L13577 . This is a "TEXAS BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 04090020102 . This is a "QUALCHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 5M095 . This is a "ARKANSAS BLUE CROSS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: P00720347 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 195221002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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