=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346333598
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RADIOLOGY ASSOCIATES OF WICHITA FALLS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 11/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 808 BROOK AVE.
-----------------------------------------------------
City | WICHITA FALLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76301-4289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-766-0217
-----------------------------------------------------
Fax | 940-766-0730
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 808 BROOK AVE.
-----------------------------------------------------
City | WICHITA FALLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76301-4289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-766-0217
-----------------------------------------------------
Fax | 940-766-0730
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL/OWNER
-----------------------------------------------------
Name | DAVID DOUGLAS MOFFATT III
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 940-766-0217
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------