=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043257686
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID H EWALT M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2006
-----------------------------------------------------
Last Update Date | 02/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4001 W 15TH ST STE 300
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-5802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-750-0808
-----------------------------------------------------
Fax | 682-303-9572
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 733784
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75373-3784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-885-1855
-----------------------------------------------------
Fax | 682-885-1396
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2088P0231X
-----------------------------------------------------
Taxonomy Name | Pediatric Urology Physician
-----------------------------------------------------
License Number | G9345
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------