Provider Demographics
NPI:1386638468
Name:DIAGNOSTIC CLINIC OF LONGVIEW PA
Entity type:Organization
Organization Name:DIAGNOSTIC CLINIC OF LONGVIEW PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DORA
Authorized Official - Middle Name:C
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-291-6062
Mailing Address - Street 1:707 HOLLYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2410
Mailing Address - Country:US
Mailing Address - Phone:903-757-6042
Mailing Address - Fax:903-232-8226
Practice Address - Street 1:707 HOLLYBROOK DR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2410
Practice Address - Country:US
Practice Address - Phone:903-757-6042
Practice Address - Fax:903-232-8226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 207RI0011X, 207V00000X, 207X00000X, 207Y00000X, 208000000X, 2084N0400X, 208600000X, 207UN0901X, 213ES0103X, 207R00000X
TX207RS0012X, 207RG0100X, 207Q00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130964306Medicaid
TX130964302Medicaid
TX45D0482673OtherDME RR MEDICARE
TX130964307Medicaid
TX45D0482673OtherDME RR MEDICARE
TX00T453Medicare PIN