Healthcare Provider Details

I. General information

NPI: 1184935975
Provider Name (Legal Business Name): JASON R EHRHARDT CNIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 09/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 WATERVIEW PKWY STE 305
RICHARDSON TX
75080-1472
US

IV. Provider business mailing address

3400 WATERVIEW PARKWAY SUITE 305
RICHARDSON TX
75080
US

V. Phone/Fax

Practice location:
  • Phone: 214-295-6703
  • Fax: 214-245-5267
Mailing address:
  • Phone: 214-295-6703
  • Fax: 214-245-5267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number1235
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: