Provider Demographics
NPI:1366414773
Name:PACKWOOD, ERIC ALAN (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:ALAN
Last Name:PACKWOOD
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 1:321 S HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-1016
Mailing Address - Country:US
Mailing Address - Phone:817-529-9949
Mailing Address - Fax:817-529-9943
Practice Address - Street 1:321 S HENDERSON ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-1016
Practice Address - Country:US
Practice Address - Phone:817-529-9949
Practice Address - Fax:817-529-9943
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0479207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018440004Medicaid
TX152778001Medicaid
120897101OtherPHCS FIRST CARE 12940
018440004OtherAMERIGROUP
139925100OtherFIRST CARE STAR MEDICAID
7931102OtherAETNA
H41514OtherCIGNA OPTICARE
TX8G6221OtherBCBS
8G6220OtherBCBS
P00075436OtherRAILROAD MEDICARE
TX152778001Medicaid
H41514Medicare UPIN