Provider Demographics
NPI:1114950359
Name:DOCEKAL, LORETTA FERN (PA)
Entity Type:Individual
Prefix:MS
First Name:LORETTA
Middle Name:FERN
Last Name:DOCEKAL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3090 N. GOLIAD SUITE 110
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087
Mailing Address - Country:US
Mailing Address - Phone:972-722-0011
Mailing Address - Fax:972-722-0023
Practice Address - Street 1:3090 N. GOLIAD SUITE 110
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087
Practice Address - Country:US
Practice Address - Phone:972-722-0011
Practice Address - Fax:972-722-0023
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10001357363AM0700X, 363A00000X
TXPA00956363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1017116OtherPA CERTIFICATION
WA0224086OtherLABOR & INDUSTRIES
WA8945047OtherCRIME VICTIMS
WAPA10001357OtherPA LICENSE
WA8465411Medicaid
1017116OtherPA CERTIFICATION
WA8867629Medicare PIN