Provider Demographics
NPI:1790832749
Name:EAST TEXAS PSYCHIATRY ASSOCIATES
Entity Type:Organization
Organization Name:EAST TEXAS PSYCHIATRY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHROKH
Authorized Official - Middle Name:
Authorized Official - Last Name:SAFARIMARYAKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-297-6500
Mailing Address - Street 1:PO BOX 5329
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75608-5329
Mailing Address - Country:US
Mailing Address - Phone:903-297-6500
Mailing Address - Fax:903-663-1085
Practice Address - Street 1:22 BERMUDA LN
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2902
Practice Address - Country:US
Practice Address - Phone:903-297-6500
Practice Address - Fax:903-663-1085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171015401Medicaid
TX0098KZOtherBCBS
TX171015401Medicaid