Provider Demographics
NPI:1942475322
Name:NORTHEAST TEXAS PLASTIC SURGERY, PA
Entity Type:Organization
Organization Name:NORTHEAST TEXAS PLASTIC SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:JANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-572-9050
Mailing Address - Street 1:301 W 18TH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:MT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455
Mailing Address - Country:US
Mailing Address - Phone:903-572-9050
Mailing Address - Fax:903-572-9051
Practice Address - Street 1:301 W 18TH ST
Practice Address - Street 2:STE 101
Practice Address - City:MT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455
Practice Address - Country:US
Practice Address - Phone:903-572-9050
Practice Address - Fax:903-572-9051
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVID A JANSEN MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-25
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8737208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty