Provider Demographics
NPI:1639300288
Name:GEORGETOWN PULMONARY ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:GEORGETOWN PULMONARY ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:R
Authorized Official - Last Name:DEKERATRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-819-0132
Mailing Address - Street 1:PO BOX 679706
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-9706
Mailing Address - Country:US
Mailing Address - Phone:512-819-0132
Mailing Address - Fax:512-819-9335
Practice Address - Street 1:1900 SCENIC DRIVE
Practice Address - Street 2:SUITE 2208
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7703
Practice Address - Country:US
Practice Address - Phone:512-819-0132
Practice Address - Fax:512-819-9335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-30
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0787207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2064198-01Medicaid
TX2064198-01Medicaid