Provider Demographics
NPI:1548254188
Name:DEFREITAS, JUNIOR (MD)
Entity type:Individual
Prefix:DR
First Name:JUNIOR
Middle Name:
Last Name:DEFREITAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3324 COLORADO BLVD
Mailing Address - Street 2:STE 103
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210
Mailing Address - Country:US
Mailing Address - Phone:940-891-1788
Mailing Address - Fax:940-891-1658
Practice Address - Street 1:3324 COLORADO BLVD
Practice Address - Street 2:STE 103
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210
Practice Address - Country:US
Practice Address - Phone:940-891-1788
Practice Address - Fax:940-891-1658
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9655174400000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX036291501Medicaid
TX036291501Medicaid
TX00U30CMedicare PIN