Provider Demographics
NPI:1376773168
Name:INTEGRATED INFECTIOUS DISEASES, PLLC
Entity Type:Organization
Organization Name:INTEGRATED INFECTIOUS DISEASES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:C
Authorized Official - Last Name:MBONU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-614-5050
Mailing Address - Street 1:P.O. BOX 7707
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505
Mailing Address - Country:US
Mailing Address - Phone:903-614-5001
Mailing Address - Fax:903-614-5077
Practice Address - Street 1:2604 ST. MICHAEL DRIVE
Practice Address - Street 2:SUITE 310
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503
Practice Address - Country:US
Practice Address - Phone:903-614-5001
Practice Address - Fax:903-614-5077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-15
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty