Provider Demographics
NPI:1508027020
Name:DUFFY, THARREN CHARLES (DO)
Entity Type:Individual
Prefix:DR
First Name:THARREN
Middle Name:CHARLES
Last Name:DUFFY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-593-8441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017607207P00000X
TXP1292207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX296518802Medicaid
TX296518805Medicaid
TX750818167044OtherTRICARE
TX750818167048OtherTRICARE
TX296518803Medicaid
TX751976930005OtherTRICARE
TXP01231382OtherRAILROAD MCARE
TX296518806Medicaid
TX750818167022OtherTRICARE
TX8DD749OtherBCBS
TX8DD752OtherBCBS
TX8X8165OtherBCBS
TX750818167015OtherTRICARE
TXTXB156887Medicare Oscar/Certification
TX274373YMLBMedicare PIN
TXTXB157143Medicare Oscar/Certification
TX296518802Medicaid