Provider Demographics
NPI:1871973867
Name:IRVING COPPELL PRIMARY CARE DOCTORS PLLC
Entity type:Organization
Organization Name:IRVING COPPELL PRIMARY CARE DOCTORS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAYALAKSHMI
Authorized Official - Middle Name:
Authorized Official - Last Name:RAGHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-905-3915
Mailing Address - Street 1:PO BOX 15885
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4053
Mailing Address - Country:US
Mailing Address - Phone:972-905-3915
Mailing Address - Fax:940-205-4525
Practice Address - Street 1:309 REGENCY PKWY
Practice Address - Street 2:SUITE #107
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5165
Practice Address - Country:US
Practice Address - Phone:972-905-3915
Practice Address - Fax:940-205-4525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-04
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX439112Medicare PIN