Provider Demographics
NPI:1841814506
Name:KEVIN B. WALDREP, M.D.,PLLC
Entity type:Organization
Organization Name:KEVIN B. WALDREP, M.D.,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIAL/DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANCISCO
Authorized Official - Middle Name:A
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-566-4204
Mailing Address - Street 1:7777 FOREST LN STE B111
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2539
Mailing Address - Country:US
Mailing Address - Phone:972-566-4204
Mailing Address - Fax:
Practice Address - Street 1:7777 FOREST LN STE B111
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2539
Practice Address - Country:US
Practice Address - Phone:972-566-4204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-28
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty