Provider Demographics
NPI:1619023355
Name:CANCER CARE NETWORK OF SOUTH TEXAS PA
Entity Type:Organization
Organization Name:CANCER CARE NETWORK OF SOUTH TEXAS PA
Other - Org Name:MARBLE FALLS OFFICE-S.A.TUMOR & BLOOD CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-545-6972
Mailing Address - Street 1:715 FM 1431E
Mailing Address - Street 2:
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654
Mailing Address - Country:US
Mailing Address - Phone:830-693-0555
Mailing Address - Fax:
Practice Address - Street 1:715 FM 1431E
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654
Practice Address - Country:US
Practice Address - Phone:830-693-0555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9664207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX109514302Medicaid
TX00U40QOtherBLUECROSS BLUESHIELD TX
TX109514302Medicaid
TX00U40QOtherBLUECROSS BLUESHIELD TX
TX=========OtherTAX ID