Healthcare Provider Details

I. General information

NPI: 1023198637
Provider Name (Legal Business Name): TYLER KIDNEY DOCTORS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 OLYMPIC PLAZA CIR 912
TYLER TX
75701-1951
US

IV. Provider business mailing address

PO BOX 132506
TYLER TX
75713-2506
US

V. Phone/Fax

Practice location:
  • Phone: 903-594-2293
  • Fax: 903-848-9513
Mailing address:
  • Phone: 903-594-2293
  • Fax: 903-566-0167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberJ8518
License Number StateTX

VIII. Authorized Official

Name: ROBERT C DOBROWOLSKI
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 903-594-2293