=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952679219
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONALD WAYNE CALLAWAY JR. ATP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2011
-----------------------------------------------------
Last Update Date | 12/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 118 S PARK DR STE A
-----------------------------------------------------
City | BROWNWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76801-5957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-643-3290
-----------------------------------------------------
Fax | 325-643-3295
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1315 AVENUE C
-----------------------------------------------------
City | BROWNWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76801-3422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-642-4765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number | 0107430
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------