Provider Demographics
NPI:1962432146
Name:HEDGEPETH, JAMES D
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:D
Last Name:HEDGEPETH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11481 TOEPPERWEIN RD
Mailing Address - Street 2:SUITE 1201
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3145
Mailing Address - Country:US
Mailing Address - Phone:210-599-8903
Mailing Address - Fax:210-599-9035
Practice Address - Street 1:11481 TOEPPERWEIN RD
Practice Address - Street 2:SUITE 1201
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233
Practice Address - Country:US
Practice Address - Phone:210-599-8903
Practice Address - Fax:210-599-9035
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX169110174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX062809102Medicaid
TX650384Medicare ID - Type Unspecified
TX062809102Medicaid