Provider Demographics
NPI:1093182305
Name:NORTH TEXAS KIDNEY DISEASE ASSOCIATES
Entity Type:Organization
Organization Name:NORTH TEXAS KIDNEY DISEASE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-320-1708
Mailing Address - Street 1:3315 COLORADO BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-6884
Mailing Address - Country:US
Mailing Address - Phone:940-320-1708
Mailing Address - Fax:940-565-5457
Practice Address - Street 1:2609 SCRIPTURE ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201
Practice Address - Country:US
Practice Address - Phone:940-320-1708
Practice Address - Fax:940-565-5457
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH TEXAS KIDNEY DISEASE ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-24
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146883702Medicaid
TX00672RMedicare PIN