Provider Demographics
NPI:1245847672
Name:EAST TEXAS FUNCTIONAL MEDICINE CENTER, LLC
Entity type:Organization
Organization Name:EAST TEXAS FUNCTIONAL MEDICINE CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUY
Authorized Official - Middle Name:OTIS
Authorized Official - Last Name:DANIELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-595-8077
Mailing Address - Street 1:419 WSW LOOP 323 STE 400
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-7063
Mailing Address - Country:US
Mailing Address - Phone:903-595-8077
Mailing Address - Fax:
Practice Address - Street 1:419 WSW LOOP 323 STE 400
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-7063
Practice Address - Country:US
Practice Address - Phone:903-595-8077
Practice Address - Fax:903-363-1541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-29
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1801905674OtherDR. DANIELSON'S NPI NUMBER