Provider Demographics
NPI:1689619132
Name:PAPPAS MEDICAL CLINIC PA
Entity Type:Organization
Organization Name:PAPPAS MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PUIFUN
Authorized Official - Middle Name:LILA
Authorized Official - Last Name:PAPPAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-831-6312
Mailing Address - Street 1:4110 RICHMOND PL
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0001
Mailing Address - Country:US
Mailing Address - Phone:903-831-6312
Mailing Address - Fax:903-838-3613
Practice Address - Street 1:4110 RICHMOND PL
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-0001
Practice Address - Country:US
Practice Address - Phone:903-831-6312
Practice Address - Fax:903-838-3613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165546601Medicaid
AR154345002Medicaid
AR9R062OtherBLUE CROSS
TX0050LEOtherBLUE CROSS
TXDC2163OtherRAILROAD MEDICARE
TX165546601Medicaid
TX00810WMedicare PIN