Provider Demographics
NPI:1669611778
Name:WICHITA DIAGNOSTIC PARTNERS, PLLC
Entity type:Organization
Organization Name:WICHITA DIAGNOSTIC PARTNERS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:KAMERON
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-654-9911
Mailing Address - Street 1:639 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-3015
Mailing Address - Country:US
Mailing Address - Phone:866-654-9911
Mailing Address - Fax:
Practice Address - Street 1:639 N 13TH ST
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-3015
Practice Address - Country:US
Practice Address - Phone:866-654-9911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A3650Medicare PIN