Provider Demographics
NPI:1851439780
Name:JEFFREY A FEARON MD P A
Entity Type:Organization
Organization Name:JEFFREY A FEARON MD P A
Other - Org Name:THE CRANIOFACIAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALONDRA
Authorized Official - Middle Name:E
Authorized Official - Last Name:TIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA CFO CMOM
Authorized Official - Phone:972-566-6464
Mailing Address - Street 1:7777 FOREST LN STE C700
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2518
Mailing Address - Country:US
Mailing Address - Phone:972-566-6464
Mailing Address - Fax:972-566-6279
Practice Address - Street 1:7777 FOREST LN STE C700
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2518
Practice Address - Country:US
Practice Address - Phone:972-566-6464
Practice Address - Fax:972-566-6279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH86382086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093725201Medicaid
TX093725201Medicaid
TX00F48LMedicare PIN
TX093725201Medicaid