Provider Demographics
NPI:1205024635
Name:EDWIN R. DUPPSTADT M.D. AND ASSOCIATES PA
Entity type:Organization
Organization Name:EDWIN R. DUPPSTADT M.D. AND ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:DUPPSTADT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-465-7661
Mailing Address - Street 1:3223 OMEGA DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76014-2006
Mailing Address - Country:US
Mailing Address - Phone:817-465-7661
Mailing Address - Fax:817-465-7679
Practice Address - Street 1:3223 OMEGA DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-2006
Practice Address - Country:US
Practice Address - Phone:817-465-7661
Practice Address - Fax:817-465-7679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00510HMedicare PIN