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General NPI Number Information
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NPI Number | 1407052103
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Entity Type | Individual
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Provider Name | JOEL E. GANGROSS LAT
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Gender | Male
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Dates
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Enumeration Date | 06/21/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3414 GOLDEN RD
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City | TYLER
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State | TX
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Zip | 75701-8336
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Country | US
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Telephone | 903-939-7500
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Fax | 903-597-1245
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Provider Business Mailing Address
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Address Line | 12002 COUNTY ROAD 4401
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City | LARUE
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State | TX
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Zip | 75770-6101
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Country | US
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Telephone | 903-830-0604
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | AT2040
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License Number State | TX
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