Healthcare Provider Details

I. General information

NPI: 1003080185
Provider Name (Legal Business Name): GREGORY D POWELL, MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 MAPLE AVE STE. 100
DALLAS TX
75235-6519
US

IV. Provider business mailing address

5701 MAPLE AVE STE. 100
DALLAS TX
75235-6519
US

V. Phone/Fax

Practice location:
  • Phone: 214-351-6600
  • Fax: 214-351-5046
Mailing address:
  • Phone: 214-351-6600
  • Fax: 214-351-5046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberJ3877
License Number StateTX

VIII. Authorized Official

Name: LISA CONTRERAS
Title or Position: BUSINESS OFFICE SUPERVISOR
Credential:
Phone: 214-654-2129