=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215042189
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARITAS FAMILY MEDICINE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2006
-----------------------------------------------------
Last Update Date | 04/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11901 TOEPPERWEIN RD SUITE 1201
-----------------------------------------------------
City | LIVE OAK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78233-3161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-650-9066
-----------------------------------------------------
Fax | 210-650-9067
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11901 TOEPPERWEIN RD SUITE 1201
-----------------------------------------------------
City | LIVE OAK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78233-3161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-650-9066
-----------------------------------------------------
Fax | 210-650-9067
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JEFFREY ALEXANDER CANNON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 210-650-9066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | L8002
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------