Provider Demographics
NPI: | 1477558245 |
---|---|
Name: | ALLING, JEFFERSON B (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | JEFFERSON |
Middle Name: | B |
Last Name: | ALLING |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1001 W EAGLE DR |
Mailing Address - Street 2: | |
Mailing Address - City: | DECATUR |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 76234-3745 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 940-627-7443 |
Mailing Address - Fax: | 940-627-8326 |
Practice Address - Street 1: | 1001 W EAGLE DR |
Practice Address - Street 2: | |
Practice Address - City: | DECATUR |
Practice Address - State: | TX |
Practice Address - Zip Code: | 76234-3745 |
Practice Address - Country: | US |
Practice Address - Phone: | 940-627-7443 |
Practice Address - Fax: | 940-627-8326 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-06-16 |
Last Update Date: | 2016-09-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | H4125 | 207Q00000X, 208000000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 080081332 | Other | RAILROAD MEDICARE |
TX | 130732401 | Medicaid | |
TX | 130732408 | Medicaid | |
TX | 130732401 | Medicaid | |
TX | 8E0102 | Medicare PIN |