Provider Demographics
NPI:1437426723
Name:NORTH CENTRAL TEXAS INFECTIOUS DISEASE GROUP PA
Entity Type:Organization
Organization Name:NORTH CENTRAL TEXAS INFECTIOUS DISEASE GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.O./PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMOYE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-921-1886
Mailing Address - Street 1:1169 N BURLESON BLVD
Mailing Address - Street 2:SUITE 107-235
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7011
Mailing Address - Country:US
Mailing Address - Phone:817-921-1886
Mailing Address - Fax:
Practice Address - Street 1:650 SAINT LOUIS AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3346
Practice Address - Country:US
Practice Address - Phone:817-921-1886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB144821Medicare PIN