Healthcare Provider Details

I. General information

NPI: 1962408674
Provider Name (Legal Business Name): AUSTIN REEVES D P M
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 04/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 MCKNIGHT RD
TEXARKANA TX
75503-0921
US

IV. Provider business mailing address

4110 MCKNIGHT RD
TEXARKANA TX
75503-0921
US

V. Phone/Fax

Practice location:
  • Phone: 903-223-6000
  • Fax: 903-223-6016
Mailing address:
  • Phone: 903-223-6000
  • Fax: 903-223-6016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1369
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number178
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberP0002214
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: