Provider Demographics
NPI:1639135734
Name:HUMPHRIES, KATHLEEN E (DO)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:E
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 S. CARRIER PWKY.
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-1517
Mailing Address - Country:US
Mailing Address - Phone:972-262-1425
Mailing Address - Fax:972-262-4973
Practice Address - Street 1:820 S. CARRIER PWKY.
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1517
Practice Address - Country:US
Practice Address - Phone:972-262-1425
Practice Address - Fax:972-262-4973
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6305207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX047814105Medicaid
TX047814105Medicaid
TX8L16675Medicare PIN
TXE52168Medicare UPIN