Provider Demographics
NPI:1447448063
Name:DOUGLAS AVENUE MEDICAL MANAGEMENT CO
Entity type:Organization
Organization Name:DOUGLAS AVENUE MEDICAL MANAGEMENT CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:ALBERTO
Authorized Official - Middle Name:RICARDO
Authorized Official - Last Name:ROCHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-522-3930
Mailing Address - Street 1:3330 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-2717
Mailing Address - Country:US
Mailing Address - Phone:214-522-3930
Mailing Address - Fax:
Practice Address - Street 1:3330 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-2717
Practice Address - Country:US
Practice Address - Phone:214-522-3930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
D3385208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00224WOtherMEDICARE GROUP #