Provider Demographics
NPI:1568737708
Name:DIAMONDBACK PAIN PA
Entity Type:Organization
Organization Name:DIAMONDBACK PAIN PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-691-2975
Mailing Address - Street 1:1025 DESHONG DR
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-9330
Mailing Address - Country:US
Mailing Address - Phone:214-691-2975
Mailing Address - Fax:903-737-0125
Practice Address - Street 1:1025 DESHONG DR
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-9330
Practice Address - Country:US
Practice Address - Phone:214-691-2975
Practice Address - Fax:903-737-0125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4283208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8F20820Medicare UPIN