=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740340728
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CONNIE MAILEG MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2006
-----------------------------------------------------
Last Update Date | 07/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 619 MATLOCK CENTRE CIRCLE
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-860-9936
-----------------------------------------------------
Fax | 817-861-4101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 619 MATLOCK CENTRE CIRCLE
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-860-9936
-----------------------------------------------------
Fax | 817-861-4101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | F2784
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------