Provider Demographics
NPI:1972577419
Name:FANNING, PAUL M (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:M
Last Name:FANNING
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:1720 S BECKHAM AVE STE 104
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-4464
Practice Address - Country:US
Practice Address - Phone:903-597-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6425207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1972577419Medicaid
TX123074OtherSUPERIOR HEALTH CHIPS
TX75-2616977-136OtherTRICARE
TX129809306Medicaid
TX45-2578435-002OtherTRICARE
TX83Y684OtherBCBS OF TEXAS
TX5623482OtherAETNA
TXP01572864OtherRAIL ROAD MEDICARE
TX752616977022OtherHUMAN SOUTH MILITARY TRICARE
TX8FM313OtherBCBS
TX129809302Medicaid
TX457359YR7VMedicare PIN
TX45-2578435-002OtherTRICARE
G47664Medicare UPIN
TXTXB110788Medicare Oscar/Certification