Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 207QS0010X | Family Medicine | Sports Medicine | L7909 | TEXAS | No |
| 2 | 207Q00000X | Family Medicine | | L7909 | TEXAS | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 129375 | OTHER | TEXAS | CHIPS |
| 2 | TIN PLUS 001 | OTHER | TEXAS | TRICARE CANTON LOCATION |
| 3 | 8K1901 | OTHER | TEXAS | TEXAS BCBS |
| 4 | 166412001 | MEDICAID | TEXAS | |
| 5 | P00165779 | OTHER | TEXAS | RAILROAD MEDICARE |
| 6 | 8V5495 | OTHER | TEXAS | BCBS |
| 7 | 8B6338 | MEDICARE ID-TYPE UNSPECIFIED | TEXAS | |
| 8 | 166412003 | MEDICAID | TEXAS | |
| 9 | P00886861 | MEDICARE PIN | TEXAS | |
| 10 | 138771100 | OTHER | TEXAS | FIRSTCARE SOUTHWEST |
| 11 | TIN PLUS 028 | OTHER | TEXAS | TRICARE |
| 12 | TIN PLUS 002 | OTHER | TEXAS | TRICARE LAKE PALESTINE LOCATION |
| 13 | TXB114779 | MEDICARE OSCAR/CERTIFICATION | TEXAS | |
| 14 | PP10013213 | OTHER | TEXAS | TEXAS WORKERS COMP |
| 15 | I04869 | MEDICARE UPIN | TEXAS | |
