=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447448063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOUGLAS AVENUE MEDICAL MANAGEMENT CO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2007
-----------------------------------------------------
Last Update Date | 10/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3330 DOUGLAS AVE
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75219-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-522-3930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3330 DOUGLAS AVE
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75219-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-522-3930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OPERATIONS
-----------------------------------------------------
Name | MR. ALBERTO RICARDO ROCHA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-522-3930
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | D3385
-----------------------------------------------------
License Number State |
-----------------------------------------------------