Provider Demographics
NPI:1649592205
Name:JOHN ALLEN VAN WAGONER M.D. P.A.
Entity Type:Organization
Organization Name:JOHN ALLEN VAN WAGONER M.D. P.A.
Other - Org Name:SOUTHWEST ALLERGY & ASTHMA CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:VAN WAGONER
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:972-398-3500
Mailing Address - Street 1:6101 WINDCOM COURT
Mailing Address - Street 2:STE 400
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-7817
Mailing Address - Country:US
Mailing Address - Phone:972-398-3500
Mailing Address - Fax:972-398-3512
Practice Address - Street 1:3105 COLORADO BLVD.
Practice Address - Street 2:STE 150
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210
Practice Address - Country:US
Practice Address - Phone:972-398-3500
Practice Address - Fax:972-398-3512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8854207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH65483Medicare UPIN