=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104451079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DANIEL DALTON DUBOSE, MD, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2020
-----------------------------------------------------
Last Update Date | 03/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 CROWN POINTE BLVD STE 200
-----------------------------------------------------
City | WILLOW PARK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76087-1304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-989-9733
-----------------------------------------------------
Fax | 817-989-9723
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 CROWN POINTE BLVD STE 200
-----------------------------------------------------
City | WILLOW PARK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76087-1304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-989-9733
-----------------------------------------------------
Fax | 817-989-9723
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANIEL DALTON DUBOSE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 817-989-9733
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------