Provider Demographics
NPI:1447242128
Name:FACKLER, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:FACKLER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:17183 INTERSTATE 45 S
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77385-3312
Mailing Address - Country:US
Mailing Address - Phone:936-321-8000
Mailing Address - Fax:936-271-0122
Practice Address - Street 1:17183 INTERSTATE 45 S
Practice Address - Street 2:SUITE 210
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77385-3312
Practice Address - Country:US
Practice Address - Phone:936-321-8000
Practice Address - Fax:936-271-0122
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2017-05-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXK2687207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX031123503Medicaid
TXP01570351OtherRR MEDICARE
TX8FX417OtherBCBS
TXP01725660OtherRR MEDICARE
TX031123502Medicaid
TX8FB144OtherBLUE CROSS BLUE SHIELD
TX031123501Medicaid
TX8FX417OtherBCBS
TX031123503Medicaid
TXP01725660OtherRR MEDICARE
TXP01570351OtherRR MEDICARE