Healthcare Provider Details

I. General information

NPI: 1316728702
Provider Name (Legal Business Name): HEALTHTEXAS PROVIDER NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2023
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SE AVE A
IDABEL OK
74745-4620
US

IV. Provider business mailing address

301 N WASHINGTON AVE
DALLAS TX
75246-1754
US

V. Phone/Fax

Practice location:
  • Phone: 580-208-2700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE J TELFORD
Title or Position: MANAGED CARE CONSULTANT
Credential:
Phone: 214-865-2774