For Health Care Providers Who Are Individuals |
NPI (This is the provider’s NPI. If the provider has had an NPI replaced, this will be the same NPI as the Replacement NPI.) |
Entity Type Code
1=Individual |
Replacement NPI (This is the provider’s NPI if the provider has been assigned a Replacement NPI. If the provider has never been assigned a Replacement NPI, this data element will be blank.) |
Provider Last Name (Legal Name) |
Provider First Name |
Provider Middle Name |
Provider Other Last Name |
Provider Other Last Name Type Code
1=Former Name
2=Professional name
5=Other |
Provider Other First Name |
Provider Other Middle Name |
Provider Name Prefix Text |
Provider Name Suffix Text |
Provider Credential Text |
Provider First Line Business Mailing Address |
Provider Second Line Business Mailing Address |
Provider Business Mailing Address City Name |
Provider Business Mailing Address State Name |
Provider Business Mailing Address Postal Code |
Provider Business Mailing Address Country Code (If outside U.S.) |
Provider Business Mailing Address Telephone Number |
Provider Business Mailing Address Fax Number |
Provider First Line Business Location Address |
Provider Second Line Business Location Address |
Provider Business Location Address City Name |
Provider Business Location Address State Name |
Provider Business Location Address Postal Code |
Provider Business Location Address Country Code (If outside U.S.) |
Provider Business Location Address Telephone Number |
Provider Business Location Address Fax Number |
Healthcare Provider Taxonomy Code (Primary Taxonomy is required; up to 14 additional Taxonomies may, as an option, be reported.) |
Other Provider Identifier (Up to 20 Other Provider Identifiers may, as an option, be reported.) |
Other Provider Identifier Type Code (The Other Provider Identifier Type Code is associated with an Other Provider Identifier. Because up to 20 Other Provider Identifiers may, as an option, be reported, up to 20 Other Provider Identifier Type Codes may be reported as well.) |
Provider Enumeration Date |
Last Update Date |
NPI Deactivation Reason Code |
NPI Deactivation Date |
NPI Reactivation Date |
Provider Gender Code |
Provider License Number |
Provider License Number State Code |
