Provider Demographics
NPI:1750383386
Name:EAST TEXAS VASCULAR ASSOCIATES, P.A.
Entity type:Organization
Organization Name:EAST TEXAS VASCULAR ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-595-2636
Mailing Address - Street 1:700 OLYMPIC PLAZA CIR STE 510
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1952
Mailing Address - Country:US
Mailing Address - Phone:903-595-2636
Mailing Address - Fax:903-595-5560
Practice Address - Street 1:700 OLYMPIC PLAZA CIR STE 510
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1952
Practice Address - Country:US
Practice Address - Phone:903-595-2636
Practice Address - Fax:903-595-5560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1987208600000X, 2086S0129X
TXD49812086S0129X, 208600000X
TXK08622086S0129X, 208600000X
TXH43852086S0129X, 208C00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX085672601Medicaid
TX085672601Medicaid
TX00U48ZMedicare ID - Type Unspecified