Provider Demographics
NPI:1518933308
Name:UPDEGROVE, JOHN D (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:UPDEGROVE
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 1:2457 NE COUNTY ROAD 0080
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75109-8414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2457 NE COUNTY ROAD 0080
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75109-8414
Practice Address - Country:US
Practice Address - Phone:903-654-0457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0897207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136617111Medicaid
TXP00463099OtherRAILROAD MEDICARE
TXDG9311OtherRAILROAD MEDICARE GROUP
TX00Y226OtherMEDICARE GROUP
TXC22878Medicare UPIN
TXP00463099OtherRAILROAD MEDICARE