Provider Demographics
NPI:1427314608
Name:KIDNEY DISEASE AND DIALYSIS ASSOCIATES, PA
Entity type:Organization
Organization Name:KIDNEY DISEASE AND DIALYSIS ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JABBAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-784-4487
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75461-1810
Mailing Address - Country:US
Mailing Address - Phone:903-784-4487
Mailing Address - Fax:903-784-4497
Practice Address - Street 1:870 NE LOOP 286
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-2134
Practice Address - Country:US
Practice Address - Phone:903-784-4487
Practice Address - Fax:903-784-4497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-02
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5243207RN0300X
TXM8731207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX307174801Medicaid
TX307174801Medicaid