Provider Demographics
NPI:1235317082
Name:NACOGDOCHES FAMILY PRACTICE, PA
Entity Type:Organization
Organization Name:NACOGDOCHES FAMILY PRACTICE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:EMBORGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-564-2691
Mailing Address - Street 1:PO BOX 630696
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75963
Mailing Address - Country:US
Mailing Address - Phone:936-553-2534
Mailing Address - Fax:713-634-2636
Practice Address - Street 1:1023 N MOUND ST
Practice Address - Street 2:SUITE A
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4491
Practice Address - Country:US
Practice Address - Phone:936-564-2691
Practice Address - Fax:936-560-5224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXM8458OtherTEXAS MEDICAL LICENSE
TX203713701Medicaid
TX203713701Medicaid