Provider Demographics
NPI:1629034863
Name:ORTHOPEDIC SPECIALISTS OF TEXARKANA PLLC
Entity Type:Organization
Organization Name:ORTHOPEDIC SPECIALISTS OF TEXARKANA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:DEHAAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-792-5005
Mailing Address - Street 1:PO BOX 7648
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505-7648
Mailing Address - Country:US
Mailing Address - Phone:903-792-5005
Mailing Address - Fax:903-791-1569
Practice Address - Street 1:1002 TEXAS BLVD.
Practice Address - Street 2:SUITE 501
Practice Address - City:TEXARKANA
Practice Address - State:TEXAS
Practice Address - Zip Code:75501
Practice Address - Country:UM
Practice Address - Phone:903-792-5005
Practice Address - Fax:903-791-1569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2594174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5G239OtherARKANSAS MEDICARE
TX109415302Medicaid
OK100754980AMedicaid
AR131747002Medicaid
TX94AUOtherTEXAS BCBS
TXCE7233OtherMEDICARE RAILROAD
AR85756OtherARKANSAS BCBS
TX180802400OtherDEPT OF LABOR
TXCE7233OtherMEDICARE RAILROAD
OK100754980AMedicaid