Healthcare Provider Details

I. General information

NPI: 1043307986
Provider Name (Legal Business Name): DEEP EAST TEXAS MATERNAL & FAMILY HEALTH PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W HOUSTON ST
JASPER TX
75951-4013
US

IV. Provider business mailing address

315 W HOUSTON ST
JASPER TX
75951-4013
US

V. Phone/Fax

Practice location:
  • Phone: 409-384-3430
  • Fax: 409-383-0571
Mailing address:
  • Phone: 409-384-3430
  • Fax: 409-383-0571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
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