MEDICARE: NACOGDOCHES MEDICAL CLINIC PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841248630
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NACOGDOCHES MEDICAL CLINIC PLLC

Provider Business Mailing Address
First Line	:	607 RUSSELL BLVD
Second Line	:	A
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-1247
Country	:	US
Telephone Number	:	936-560-2920
Fax Number	:	866-861-6312

Provider Business Practice Location Address
First Line	:	607 RUSSELL BLVD
Second Line	:	A
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-1247
Country	:	US
Telephone Number	:	936-560-2920
Fax Number	:	866-861-6312

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KAVITA S VYAS
Credential	:	M.D.
Telephone Number	:	936-560-2920

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	01/29/2020

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