Healthcare Provider Details

I. General information

NPI: 1699863092
Provider Name (Legal Business Name): DEEP EAST TEXAS MATERNAL AND FAMILY HEALTH, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 83 W
JASPER TX
75951
US

IV. Provider business mailing address

315 W HOUSTON
JASPER TX
75951
US

V. Phone/Fax

Practice location:
  • Phone: 409-787-4765
  • Fax: 409-787-4489
Mailing address:
  • Phone:
  • Fax: 409-383-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARTIN E GILLILAND
Title or Position: PRESIDENT
Credential: MD
Phone: 409-384-3430