Healthcare Provider Details

I. General information

NPI: 1568581775
Provider Name (Legal Business Name): THE EAGLE FORD CLINICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 03/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E. MILLER ST.
DILLEY TX
78017
US

IV. Provider business mailing address

111 E. MILLER ST.
DILLEY TX
78017
US

V. Phone/Fax

Practice location:
  • Phone: 830-965-1684
  • Fax: 830-965-1278
Mailing address:
  • Phone: 830-965-1684
  • Fax: 830-965-1278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: SURESH V DUTTA JR.
Title or Position: MD/OWNER
Credential: MD
Phone: 830-965-1684