Provider Demographics
NPI:1821016676
Name:ANDRE P DESIRE, MD, PA
Entity Type:Organization
Organization Name:ANDRE P DESIRE, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DESIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-687-5000
Mailing Address - Street 1:1631 11TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-4320
Mailing Address - Country:US
Mailing Address - Phone:940-687-5000
Mailing Address - Fax:940-687-4000
Practice Address - Street 1:1631 11TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4320
Practice Address - Country:US
Practice Address - Phone:940-687-5000
Practice Address - Fax:940-687-4000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174352801Medicaid
060063342OtherMEDICARE B - RR
TX174352801Medicaid