Provider Demographics
NPI:1003019464
Name:EARLS, ISSAC DAWON I
Entity Type:Individual
Prefix:MR
First Name:ISSAC
Middle Name:DAWON
Last Name:EARLS
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 MAGIN MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78744-5248
Mailing Address - Country:US
Mailing Address - Phone:512-947-7875
Mailing Address - Fax:
Practice Address - Street 1:4502 MAGIN MEADOW DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78744-5248
Practice Address - Country:US
Practice Address - Phone:512-947-7875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXEARL1278Medicaid