Provider Demographics
NPI:1265912430
Name:DUCKWALL, HOUSTON (RDLD)
Entity type:Individual
Prefix:
First Name:HOUSTON
Middle Name:
Last Name:DUCKWALL
Suffix:
Gender:M
Credentials:RDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3023 PERRYTON PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:PAMPA
Mailing Address - State:TX
Mailing Address - Zip Code:79065-2817
Mailing Address - Country:US
Mailing Address - Phone:806-665-0801
Mailing Address - Fax:806-665-8503
Practice Address - Street 1:ONE MEDICAL PLAZA
Practice Address - Street 2:
Practice Address - City:PAMPA
Practice Address - State:TX
Practice Address - Zip Code:79065
Practice Address - Country:US
Practice Address - Phone:806-665-3721
Practice Address - Fax:806-663-5655
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85411133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86069871OtherCOMMISSION ON DIETETIC REGISTRATION
TXDT85411OtherTEXAS DEPT OF LICENSING AND REGULATION