Provider Demographics
NPI:1154945384
Name:VINTAGE FAMILY MEDICINE AND PEDIATRICS
Entity type:Organization
Organization Name:VINTAGE FAMILY MEDICINE AND PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-206-2630
Mailing Address - Street 1:860 HEBRON PKWY STE 201
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-5143
Mailing Address - Country:US
Mailing Address - Phone:972-296-7200
Mailing Address - Fax:214-730-4281
Practice Address - Street 1:860 HEBRON PKWY STE 201
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-5143
Practice Address - Country:US
Practice Address - Phone:972-296-7200
Practice Address - Fax:214-730-4281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-03
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty