Provider Demographics
NPI:1649646357
Name:SOUTHEAST TEXAS SELF-MANAGEMENT OF DIABETES
Entity type:Organization
Organization Name:SOUTHEAST TEXAS SELF-MANAGEMENT OF DIABETES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:HOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-835-9834
Mailing Address - Street 1:3030 NORTH ST STE 560
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1424
Mailing Address - Country:US
Mailing Address - Phone:409-835-9834
Mailing Address - Fax:409-895-3547
Practice Address - Street 1:3030 NORTH ST STE 560
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1424
Practice Address - Country:US
Practice Address - Phone:409-835-9834
Practice Address - Fax:409-895-3547
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ENDOCRINE CLINIC OF SOUTHEAST TEXAS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4950207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX085737702Medicaid
TX085737702Medicaid