=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649476482
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSHUA CHAD DEFRIECE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2007
-----------------------------------------------------
Last Update Date | 10/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25282 NORTHWEST FWY SUITE 200
-----------------------------------------------------
City | CYPRESS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77429-1081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-737-2165
-----------------------------------------------------
Fax | 281-304-0085
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25282 NORTHWEST FWY SUITE 200
-----------------------------------------------------
City | CYPRESS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77429-1081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-737-2165
-----------------------------------------------------
Fax | 281-304-0085
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 30052
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | N6854
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------