Provider Demographics
NPI:1588679047
Name:NACOGDOCHES HEMATOLOGY-ONCOLOGY CLINIC PA
Entity Type:Organization
Organization Name:NACOGDOCHES HEMATOLOGY-ONCOLOGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DYANESH BAPU
Authorized Official - Middle Name:G
Authorized Official - Last Name:RAVINDRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-559-5330
Mailing Address - Street 1:1225 N MOUND ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4028
Mailing Address - Country:US
Mailing Address - Phone:936-559-5330
Mailing Address - Fax:936-559-7140
Practice Address - Street 1:1225 N MOUND ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4028
Practice Address - Country:US
Practice Address - Phone:936-559-5330
Practice Address - Fax:936-559-7140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4204207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX152183301Medicaid
TX0062HWOtherBC/BS PROVIDER #
G69218Medicare UPIN
930120241Medicare ID - Type UnspecifiedRAILROAD MEDICARE
00584TMedicare ID - Type UnspecifiedPROVIDER #