Provider Demographics
NPI:1255847448
Name:YOUR FAMILY DOCTOR, PLLC
Entity Type:Organization
Organization Name:YOUR FAMILY DOCTOR, PLLC
Other - Org Name:YOUR FAMILY DOCTOR, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-582-6000
Mailing Address - Street 1:123 BLUE HERON DR STE 101
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77316-3192
Mailing Address - Country:US
Mailing Address - Phone:936-582-6000
Mailing Address - Fax:396-448-6404
Practice Address - Street 1:123 BLUE HERON DR STE 101
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77316-3192
Practice Address - Country:US
Practice Address - Phone:936-582-6000
Practice Address - Fax:396-448-6404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-26
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0285207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00390413OtherRAILROAD MEDICARE
TXH0285OtherLICENSE
TX0074PAOtherBCBS OF TX
TXP003904132OtherINDIVIDUAL NPI
TXC15085OtherUPIN