Provider Demographics
NPI:1760478689
Name:FANOUS, ELIAS I JR (MD)
Entity Type:Individual
Prefix:
First Name:ELIAS
Middle Name:I
Last Name:FANOUS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 OLYMPIC PLAZA CIR STE 508
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1952
Mailing Address - Country:US
Mailing Address - Phone:903-526-3030
Mailing Address - Fax:903-526-3036
Practice Address - Street 1:700 OLYMPIC PLAZA CIR
Practice Address - Street 2:STE 508
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1951
Practice Address - Country:US
Practice Address - Phone:903-526-3030
Practice Address - Fax:903-526-3036
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8030207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151497801Medicaid
TX151497801Medicaid
TX8884B0Medicare PIN