Provider Demographics
NPI:1841219755
Name:IRVINE, JAMES N (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:N
Last Name:IRVINE
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 1:1720 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3400
Mailing Address - Country:US
Mailing Address - Phone:817-453-5912
Mailing Address - Fax:817-453-2988
Practice Address - Street 1:1720 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3400
Practice Address - Country:US
Practice Address - Phone:817-453-5912
Practice Address - Fax:817-453-2988
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3502207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130519507Medicaid
TX8F0973OtherPTAN
TX615799800OtherDEPARTMENT OF LABOR- ACS #
TX870749737OtherTAX ID
TX870749737OtherTAX ID
TX130519507Medicaid