Provider Demographics
NPI:1083647945
Name:VENTIMIGLIA, JOE B (MD, PHD)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:B
Last Name:VENTIMIGLIA
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 PHEASANT LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-3436
Mailing Address - Country:US
Mailing Address - Phone:972-983-8915
Mailing Address - Fax:817-761-5365
Practice Address - Street 1:6350 DAVIS BLVD # 200
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-4762
Practice Address - Country:US
Practice Address - Phone:972-525-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0231207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133567102Medicaid
TXK0231OtherSTATE MD LICENSE NO
TX133567109Medicaid
TX80100952OtherRAILROAD MEDICARE NO
TX8F1060Medicare PIN
TXK0231OtherSTATE MD LICENSE NO
TX133567109Medicaid