Provider Demographics
NPI:1720063985
Name:PRENTICE, LINDA A (MD)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:A
Last Name:PRENTICE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 HOSPITAL PKWY STE 204
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-5936
Mailing Address - Country:US
Mailing Address - Phone:817-684-5002
Mailing Address - Fax:817-684-5150
Practice Address - Street 1:1615 HOSPITAL PKWY STE 204
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-5936
Practice Address - Country:US
Practice Address - Phone:817-684-5002
Practice Address - Fax:817-684-5150
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1003207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX046101404Medicaid
TX8BW433OtherBCBS
TX046101404Medicaid
TX8L9515Medicare PIN