Healthcare Provider Details

I. General information

NPI: 1750383386
Provider Name (Legal Business Name): EAST TEXAS VASCULAR ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 OLYMPIC PLAZA CIR STE 510
TYLER TX
75701-1952
US

IV. Provider business mailing address

700 OLYMPIC PLAZA CIR STE 510
TYLER TX
75701-1952
US

V. Phone/Fax

Practice location:
  • Phone: 903-595-2636
  • Fax: 903-595-5560
Mailing address:
  • Phone: 903-595-2636
  • Fax: 903-595-5560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberL1987
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberD4981
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberK0862
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberH4385
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberL1987
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberH4385
License Number StateTX
# 7
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberK0862
License Number StateTX
# 8
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberH4385
License Number StateTX
# 9
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD4981
License Number StateTX

VIII. Authorized Official

Name: PAM HARRIS
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 903-595-2636