=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881444040
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST TEXAS ID ASSOCIATES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2024
-----------------------------------------------------
Last Update Date | 06/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 S JOHN REDDITT DR
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75904-3120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-634-8311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 150456
-----------------------------------------------------
City | LUFKIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75915-0456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-255-7330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MANDEEP BAINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 936-255-7330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------