Provider Demographics
NPI:1073504742
Name:JEAN, ALAN B (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:B
Last Name:JEAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5667
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505-5667
Mailing Address - Country:US
Mailing Address - Phone:903-223-1014
Mailing Address - Fax:903-223-1028
Practice Address - Street 1:4102 RICHMOND MDWS
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-0067
Practice Address - Country:US
Practice Address - Phone:903-223-1014
Practice Address - Fax:903-223-1028
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG72472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117999601Medicaid
AR105242001Medicaid
D66631Medicare UPIN
AR52655Medicare ID - Type Unspecified
TX82R984Medicare ID - Type Unspecified