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General NPI Number Information
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NPI Number | 1629034863
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Entity Type | Organization
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Legal Business Name | ORTHOPEDIC SPECIALISTS OF TEXARKANA PLLC
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Dates
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Enumeration Date | 04/25/2006
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Last Update Date | 06/09/2009
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Provider Practice Location Address
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Address Line | 1002 TEXAS BLVD. SUITE 501
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City | TEXARKANA
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State | TEXAS
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Zip | 75501
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Country | UM
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Telephone | 903-792-5005
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Fax | 903-791-1569
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Provider Business Mailing Address
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Address Line | PO BOX 7648
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City | TEXARKANA
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State | TX
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Zip | 75505-7648
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Country | US
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Telephone | 903-792-5005
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Fax | 903-791-1569
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Authorized Official
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Title or Position | CEO
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Name | JEFFREY THOMAS DEHAAN
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Credential | MD
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Telephone | 903-792-5005
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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 | G2594
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License Number State | TX
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