Provider Demographics
NPI:1164622833
Name:NORTHEAST TEXAS ONCOLOGIC AND RECONSTRUCTIVE SURGERY PA
Entity Type:Organization
Organization Name:NORTHEAST TEXAS ONCOLOGIC AND RECONSTRUCTIVE SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:E
Authorized Official - Last Name:CUENCA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-563-5478
Mailing Address - Street 1:301 W 18TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-2370
Mailing Address - Country:US
Mailing Address - Phone:903-563-5478
Mailing Address - Fax:
Practice Address - Street 1:301 W 18TH ST STE 101
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-2370
Practice Address - Country:US
Practice Address - Phone:903-563-5478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTEMPORARY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty