Healthcare Provider Details

I. General information

NPI: 1770960973
Provider Name (Legal Business Name): LUMINCARE PHYSICIAN GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 03/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11350 US HWY 380 SUITE 100
CROSSROADS TX
76227-6497
US

IV. Provider business mailing address

4090 MAPLESHADE LANE SUITE 220
PLANO TX
75093-0025
US

V. Phone/Fax

Practice location:
  • Phone: 214-296-2945
  • Fax: 940-365-9656
Mailing address:
  • Phone: 469-680-4293
  • Fax: 214-313-9272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS S WON
Title or Position: MD
Credential:
Phone: 972-255-5588