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 | 174400000X | Specialist | | G58417 | CALIFORNIA | No |
| 2 | 2085R0202X | Radiology | Diagnostic Radiology | N0916 | 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 | 8BC077 | OTHER | TEXAS | BCBS OF TEXAS |
| 2 | 8CU212 | OTHER | TEXAS | BCBS JV LOCATION |
| 3 | TIN PLUS 005 | OTHER | TEXAS | TRICARE JV LOCATION |
| 4 | TIN PLUS 007 | OTHER | TEXAS | TRICARE |
| 5 | TIN PLUS 013 | OTHER | TEXAS | TRICARE |
| 6 | 8L1782 | MEDICARE OSCAR/CERTIFICATION | TEXAS | |
| 7 | P00945878 | MEDICARE PIN | TEXAS | |
| 8 | 196640003 | MEDICAID | TEXAS | |
| 9 | 8AP484 | OTHER | TEXAS | BCBS |
| 10 | 8L2480 | MEDICARE OSCAR/CERTIFICATION | TEXAS | |
| 11 | 196640002 | MEDICAID | TEXAS | |
| 12 | E50595 | MEDICARE UPIN | CALIFORNIA | |
| 13 | WG58417I | MEDICARE PIN | CALIFORNIA | |
| 14 | 196640001 | MEDICAID | TEXAS | |
| 15 | P00646782 | MEDICARE PIN | TEXAS | |
| 16 | 196640004 | MEDICAID | TEXAS | |
| 17 | TIN PLUS 113 | OTHER | TEXAS | TRICARE |
| 18 | P00642895 | MEDICARE PIN | TEXAS | |
