Provider Demographics
NPI:1619935509
Name:DIAGNOSTIC RADIOLOGY OF NACOGDOCHES
Entity Type:Organization
Organization Name:DIAGNOSTIC RADIOLOGY OF NACOGDOCHES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MORRIS
Authorized Official - Middle Name:K
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:936-462-9902
Mailing Address - Street 1:PO BOX 1888
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75403
Mailing Address - Country:US
Mailing Address - Phone:800-945-2455
Mailing Address - Fax:903-453-2541
Practice Address - Street 1:602 HURST
Practice Address - Street 2:
Practice Address - City:CENTER
Practice Address - State:TX
Practice Address - Zip Code:75935
Practice Address - Country:US
Practice Address - Phone:936-598-2781
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00411KMedicare PIN