Healthcare Provider Details

I. General information

NPI: 1306988035
Provider Name (Legal Business Name): HEATON EAR NOSE AND THROAT ASSOCIATES OF EAST TEXAS P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 03/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1136 E GRANDE BLVD
TYLER TX
75703-3982
US

IV. Provider business mailing address

1136 E GRANDE BLVD
TYLER TX
75703-3982
US

V. Phone/Fax

Practice location:
  • Phone: 903-592-5601
  • Fax: 903-595-3304
Mailing address:
  • Phone: 903-592-5601
  • Fax: 903-595-3304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: JESSICA GAMBLE
Title or Position: BILLING MANAGER
Credential:
Phone: 903-592-5601