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General NPI Number Information
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NPI Number | 1588679047
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Entity Type | Organization
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Legal Business Name | NACOGDOCHES HEMATOLOGY-ONCOLOGY CLINIC PA
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Dates
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Enumeration Date | 07/30/2006
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Last Update Date | 07/30/2010
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Provider Practice Location Address
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Address Line | 1225 N MOUND ST
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City | NACOGDOCHES
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State | TX
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Zip | 75961-4028
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Country | US
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Telephone | 936-559-5330
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Fax | 936-559-7140
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Provider Business Mailing Address
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Address Line | 1225 N MOUND ST
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City | NACOGDOCHES
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State | TX
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Zip | 75961-4028
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Country | US
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Telephone | 936-559-5330
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Fax | 936-559-7140
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Authorized Official
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Title or Position | PRESIDENT
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Name | DYANESH BAPU G RAVINDRAN
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Credential | M.D
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Telephone | 936-559-5330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number | K4204
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License Number State | TX
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