Provider Demographics
NPI:1003908351
Name:JESUS D UCOL MD PA
Entity Type:Organization
Organization Name:JESUS D UCOL MD PA
Other - Org Name:JESUS D UCOL MD
Other - Org Type:Other Name
Authorized Official - Title/Position:JESUS UCOL MD PA
Authorized Official - Prefix:
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:D
Authorized Official - Last Name:UCOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-261-3437
Mailing Address - Street 1:PO BOX 4167
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308
Mailing Address - Country:US
Mailing Address - Phone:940-761-5437
Mailing Address - Fax:940-761-5400
Practice Address - Street 1:1718 10TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301
Practice Address - Country:US
Practice Address - Phone:940-761-5437
Practice Address - Fax:940-761-5400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9407208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1211940801Medicaid
TX1211940803Medicaid
TXG00976Medicare UPIN