Provider Demographics
NPI:1295749190
Name:CRAIG YETTER, DO, P.A.
Entity type:Organization
Organization Name:CRAIG YETTER, DO, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:S
Authorized Official - Last Name:YETTER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-875-2424
Mailing Address - Street 1:2203 W LAMPASAS ST
Mailing Address - Street 2:SUITE 111
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-5644
Mailing Address - Country:US
Mailing Address - Phone:972-875-2424
Mailing Address - Fax:972-875-1244
Practice Address - Street 1:2203 W LAMPASAS ST
Practice Address - Street 2:SUITE 111
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-5644
Practice Address - Country:US
Practice Address - Phone:972-875-2424
Practice Address - Fax:972-875-1244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2916207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00X020Medicare PIN