Provider Demographics
NPI:1790930899
Name:HIGGINBOTHAM, JOHN M (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:HIGGINBOTHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12221 MERIT DRIVE
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251
Mailing Address - Country:US
Mailing Address - Phone:214-217-1900
Mailing Address - Fax:940-627-7597
Practice Address - Street 1:1300 W TERRELL AVE STE K230
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3104
Practice Address - Country:US
Practice Address - Phone:817-250-4906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4470207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX282187801Medicaid
TXB132533Medicare PIN