Provider Demographics
NPI:1861493231
Name:UCOL, JESUS D (MD PA)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:D
Last Name:UCOL
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4167
Mailing Address - Street 2:1718 10TH ST. SUITE A
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-0167
Mailing Address - Country:US
Mailing Address - Phone:940-761-5437
Mailing Address - Fax:940-761-5400
Practice Address - Street 1:1718 10TH ST
Practice Address - Street 2:STE A
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5053
Practice Address - Country:US
Practice Address - Phone:940-761-5437
Practice Address - Fax:940-761-5400
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9407208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1211948Medicaid
TX1211948Medicaid
TXG09976Medicare UPIN