Provider Demographics
NPI:1104000983
Name:THEOPHILUS S PAINTER JR MD PA
Entity Type:Organization
Organization Name:THEOPHILUS S PAINTER JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:GATLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-259-9595
Mailing Address - Street 1:PO BOX 302186
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-0037
Mailing Address - Country:US
Mailing Address - Phone:512-454-5821
Mailing Address - Fax:512-260-8831
Practice Address - Street 1:800 W 34TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1143
Practice Address - Country:US
Practice Address - Phone:512-454-5821
Practice Address - Fax:512-260-8831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXB9692207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127396303Medicaid
TX127396303Medicaid
TXC20134Medicare PIN