=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104908185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LONDA G CARRASCO MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2006
-----------------------------------------------------
Last Update Date | 05/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1911 PORT LN STE 2
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79106-2470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-359-9100
-----------------------------------------------------
Fax | 806-359-7022
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1911 PORT LN STE 2
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79106-2470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-359-9100
-----------------------------------------------------
Fax | 806-359-7022
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | J5083
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------