Provider Demographics
NPI:1063586105
Name:DKJJ, INC
Entity type:Organization
Organization Name:DKJJ, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:REAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-938-7909
Mailing Address - Street 1:101 YMCA DR
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-5124
Mailing Address - Country:US
Mailing Address - Phone:972-938-7909
Mailing Address - Fax:972-938-2966
Practice Address - Street 1:101 YMCA DR
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-5124
Practice Address - Country:US
Practice Address - Phone:972-938-7909
Practice Address - Fax:972-938-2966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008283261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHH109AOtherBCBS PROVIDER NUMBER
TXP00284959OtherMEDICARE RAILROAD
TXASC345Medicare PIN