Unknown Individual – Family Medicine Physician, NPI 1922004266

Family Medicine Physician

Unknown Individual is a healthcare provider. based in Texarkana, Texas. specializing in Family Medicine Physician. They hold a License No. C4075 (AR). The NPI Number for Unknown Individual is 1922004266

Main info

Organization

Inactive

60 Years Of Experience

Accepts Medicare Assignment

Name

Unknown Individual

NPI

1922004266

Phone

(903) 735-5330

Address

1400 COLLEGE DR

Deactivation Date

12 October 2022

Doctor Profile

Medical School Name

UNIVERSITY OF ARKANSAS COLLEGE OF MEDICINE

Secondary Phone

8707796000

Graduation Year

1966 (60 years ago)

PAC ID

5193632776

Group Practice PAC ID

4082528955

Professional Enrollment ID

I20040306000237

Data current as of

19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology

Experience28

Completeness75

Years active:0State licenses:2Digital endpointsOther names

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Provider Addresses for Unknown Individual

1400, College Drive, Texarkana, Bowie County, Texas, 75503, United States
STE 202
TEXARKANA, TX 755033575
Phone: (903) 735-5330
Fax: (903) 735-5399
Mailing address matches the actual address.

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 75503)

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Provider's Procedures

Unknown Individual performs procedures in Family Medicine Physician. See the list of HCPCS codes below.

Specialty	Practice State	HCPCS Code	Description	Service Count	Beneficiary Count
FAMILY MEDICINE	TX	83036	Hemoglobin A1C level	93	74
FAMILY MEDICINE	TX	94060	Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration	11	11

Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.

PAC ID: 4082528955View full group profile

Name	Specialty	State
SUKANTHI KOVVURU	N E U R O L O G Y	AR
Unknown Individual	-	AR
ASIS SHRESTHA (MD)	Internal Medicine	NY
JOHN M ARTHUR (MD)	Internal Medicine, Nephrology	AR
MANISH GOPE RAISINGANI	-	AR
CARL PRESTON MCCORMACK (MD)	-	AR
REBECCA A CAMP	Nurse Practitioner	AR
DR. JON RUBENOW (MD)	P S Y C H I A T R Y	AR
KATHRYN NEWTON ROWLEY (APN)	-	AR
KELSEY AGRE (APRN)	-	AR