Provider Demographics
NPI:1740353598
Name:W PENNOCK LAIRD MD PA
Entity type:Organization
Organization Name:W PENNOCK LAIRD MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOOSE
Authorized Official - Suffix:
Authorized Official - Credentials:CMOM
Authorized Official - Phone:972-331-9695
Mailing Address - Street 1:12201 MERIT DR STE 550
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-3131
Mailing Address - Country:US
Mailing Address - Phone:972-331-9700
Mailing Address - Fax:972-331-9833
Practice Address - Street 1:12201 MERIT DR STE 550
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251
Practice Address - Country:US
Practice Address - Phone:972-331-9700
Practice Address - Fax:972-331-9833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1548450216OtherNPI
TX204311909Medicaid
TX370765501Medicaid
TX1306834023OtherNPI
TX194614707Medicaid
TX1575060003Medicaid
TX157508601Medicaid
TX1790773513OtherNPI
TX370751501Medicaid
TX1417110339OtherNPI
TX1518955335OtherNPI
TX212234302Medicaid
TX1437126364OtherNPI