Provider Demographics
NPI:1518147594
Name:SOUTHLAKE ONCOLOGY
Entity Type:Organization
Organization Name:SOUTHLAKE ONCOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-416-0202
Mailing Address - Street 1:1545 E SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 280
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6465
Mailing Address - Country:US
Mailing Address - Phone:817-416-0202
Mailing Address - Fax:
Practice Address - Street 1:1545 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 280
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6465
Practice Address - Country:US
Practice Address - Phone:817-416-0202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3595207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00936YMedicare PIN