Provider Demographics
NPI:1730149147
Name:CARRASCO, JEREMY S (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:S
Last Name:CARRASCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6124 W PARKER RD
Mailing Address - Street 2:SUITE 436
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-8125
Mailing Address - Country:US
Mailing Address - Phone:972-608-3356
Mailing Address - Fax:972-608-3360
Practice Address - Street 1:6124 W PARKER RD
Practice Address - Street 2:SUITE 436
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8125
Practice Address - Country:US
Practice Address - Phone:972-608-3356
Practice Address - Fax:972-608-3360
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2579208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX612418Medicare PIN
TXI53530Medicare UPIN