Provider Demographics
NPI:1558851238
Name:IDH MEDICAL PRACTICE, P.A.
Entity Type:Organization
Organization Name:IDH MEDICAL PRACTICE, P.A.
Other - Org Name:IESO DIGITAL HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MS
Authorized Official - Phone:214-277-3969
Mailing Address - Street 1:6363 N STATE HIGHWAY 161 STE 310
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-2262
Mailing Address - Country:US
Mailing Address - Phone:214-277-3969
Mailing Address - Fax:
Practice Address - Street 1:6363 N STATE HIGHWAY 161 STE 310
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2262
Practice Address - Country:US
Practice Address - Phone:214-277-3969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IESO DIGITAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty