Provider Demographics
NPI:1972680130
Name:NORTHEAST TEXAS NEUROLOGY ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:NORTHEAST TEXAS NEUROLOGY ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JETTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-526-7055
Mailing Address - Street 1:505 S FLEISHEL AVE STE 800
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-8413
Mailing Address - Country:US
Mailing Address - Phone:903-526-7055
Mailing Address - Fax:903-593-4303
Practice Address - Street 1:505 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8413
Practice Address - Country:US
Practice Address - Phone:903-526-7055
Practice Address - Fax:903-593-4303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE62352084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115025205Medicaid
TX143629701Medicaid
TX115025205Medicaid
TX8443M1Medicare PIN
TX00197RMedicare PIN
RRB PTAN CJ3449Medicare PIN