Active NPI
Sidney Peavy
- Dentist
- Dallas, TX
National Provider Identifier
1053795245
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 31263
- Practice address
- 4828 Columbia Ave
Dallas, TX 75226-1011 - Phone
- (214) 823-0202
- NPI assigned
- Jul 17, 2015
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 31263 | TX | Primary |
Addresses
Primary practice location
4828 Columbia Ave
Dallas, TX 75226-1011
Mailing address
350 N Clark St
6TH Floor
Chicago, IL 60654-4712
Phone (312) 274-4520
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in NH
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20190226001100 | NH | Order and Referring Only - Dentist | 5890034482 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 31263 | TX | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1437091200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1437091200000",
"number": "1053795245",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "350 N CLARK ST",
"address_2": "6TH FLOOR",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606544712",
"telephone_number": "312-274-4520"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4828 COLUMBIA AVE",
"city": "DALLAS",
"state": "TX",
"postal_code": "752261011",
"telephone_number": "214-823-0202"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PEAVY",
"first_name": "SIDNEY",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2015-07-17",
"last_updated": "2015-07-17",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "TX",
"license": "31263",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Dallas, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 17, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.