Provider Demographics
NPI:1629693593
Name:MDO2, PLLC
Entity Type:Organization
Organization Name:MDO2, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OTIS
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-816-5969
Mailing Address - Street 1:3217 HUNTER LN
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-8826
Mailing Address - Country:US
Mailing Address - Phone:972-816-5969
Mailing Address - Fax:
Practice Address - Street 1:3716 STANDRIDGE DR
Practice Address - Street 2:
Practice Address - City:THE COLONY
Practice Address - State:TX
Practice Address - Zip Code:75056-4566
Practice Address - Country:US
Practice Address - Phone:972-816-5969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1194753152OtherNPPES