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General NPI Number Information
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NPI Number | 1699863092
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Entity Type | Organization
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Legal Business Name | DEEP EAST TEXAS MATERNAL AND FAMILY HEALTH, PA
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Dates
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Enumeration Date | 10/11/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | HWY 83 W
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City | JASPER
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State | TX
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Zip | 75951
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Country | US
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Telephone | 409-787-4765
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Fax | 409-787-4489
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Provider Business Mailing Address
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Address Line | 315 W HOUSTON
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City | JASPER
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State | TX
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Zip | 75951
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Country | US
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Telephone |
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Fax | 409-383-1054
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARTIN E GILLILAND
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Credential | MD
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Telephone | 409-384-3430
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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