=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891350039
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID FIELDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2019
-----------------------------------------------------
Last Update Date | 11/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1602 AVENUE Q
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79401-4732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-264-0330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13322 EXECUTIVE ACRES RD
-----------------------------------------------------
City | BRAINERD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56401-5267
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-418-9530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 78209
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | T9681
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------