Provider Demographics
NPI:1033423801
Name:VASCULAR SURGERY OF NACOGDOCHES, P.A.
Entity Type:Organization
Organization Name:VASCULAR SURGERY OF NACOGDOCHES, P.A.
Other - Org Name:VASCULAR ACCESS CENTER OF EAST TEXAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALFORD
Authorized Official - Last Name:RANDEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-568-9993
Mailing Address - Street 1:PO BOX 630668
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75963-0668
Mailing Address - Country:US
Mailing Address - Phone:936-568-9993
Mailing Address - Fax:936-568-9996
Practice Address - Street 1:3618 NORTH UNIVERSITY DRIVE
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2539
Practice Address - Country:US
Practice Address - Phone:936-568-9993
Practice Address - Fax:936-568-9996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-03
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6529208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0016TYOtherBLUE CROSS BLUE SHIELD
TX220035402Medicaid
TX220035401Medicaid
TXTXB114936Medicare PIN