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General NPI Number Information
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NPI Number | 1699958124
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Entity Type | Organization
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Legal Business Name | EAST TEXAS UROCENTER
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Dates
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Enumeration Date | 12/06/2007
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Last Update Date | 12/06/2007
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Provider Practice Location Address
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Address Line | 1320 N UNIVERSITY DR STE A
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City | NACOGDOCHES
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State | TX
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Zip | 75961-4270
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Country | US
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Telephone | 936-560-5200
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Fax | 936-560-5222
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Provider Business Mailing Address
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Address Line | 1320 N UNIVERSITY DR STE A
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City | NACOGDOCHES
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State | TX
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Zip | 75961-4270
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Country | US
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Telephone | 936-560-5200
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Fax | 936-560-5222
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Authorized Official
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Title or Position | OWNER
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Name | DR. SERGIO G MOREIRA JR.
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Credential | MD
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Telephone | 936-560-5200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | M8194
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License Number State | TX
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