Provider Demographics
NPI:1013949197
Name:EGERTON, DAVID (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:EGERTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 WALLACE BLVD
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT.
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1708
Mailing Address - Country:US
Mailing Address - Phone:806-351-3777
Mailing Address - Fax:806-351-3765
Practice Address - Street 1:1400 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1786
Practice Address - Country:US
Practice Address - Phone:806-351-3777
Practice Address - Fax:806-351-3765
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24263103T00000X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100841260 AMedicaid
TX038409104Medicaid
TX038409102Medicaid
NM19708017Medicaid
TX8L21691Medicare PIN
R69741Medicare UPIN
TX038409102Medicaid