Provider Demographics
NPI:1962518191
Name:MCCOY, MICHAEL WAYNE (MDPA)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:MCCOY
Suffix:
Gender:M
Credentials:MDPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 IRA E WOODS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-4012
Mailing Address - Country:US
Mailing Address - Phone:817-481-3585
Mailing Address - Fax:817-421-6529
Practice Address - Street 1:811 IRA E WOODS AVE
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-4012
Practice Address - Country:US
Practice Address - Phone:817-481-3585
Practice Address - Fax:817-421-6529
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5589208000000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE56705Medicare UPIN