Provider Demographics
NPI:1407800857
Name:TEXOMACARE
Entity Type:Organization
Organization Name:TEXOMACARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-768-3300
Mailing Address - Street 1:5012 US HWY 75 S, SUITE 300
Mailing Address - Street 2:ATT: BILLING
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020
Mailing Address - Country:US
Mailing Address - Phone:903-416-1726
Mailing Address - Fax:903-416-1701
Practice Address - Street 1:500 BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446-3643
Practice Address - Country:US
Practice Address - Phone:580-795-5506
Practice Address - Fax:580-795-5145
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TEXOMACARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-20
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100754740AMedicaid
OKCH3977OtherRR MEDICARE
OK=========Medicare PIN