=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760618706
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINOR EMERGENCY & DIAGNOSTIC CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2009
-----------------------------------------------------
Last Update Date | 06/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1920 N COLLINS BLVD
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75080-3525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-498-4503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1920 N COLLINS BLVD
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75080-3525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-498-4503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | EDUARDO MARIO WILKINSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 972-498-4503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | J3937
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | H3144
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------