MEDICARE: NACOGDOCHES HEMATOLOGY-ONCOLOGY CLINIC PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RH0003X	Hematology & Oncology Physician	K4204	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0062HW	OTHER	TX	BC/BS PROVIDER #

General Provider Information

NPI Number	:	1588679047
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NACOGDOCHES HEMATOLOGY-ONCOLOGY CLINIC PA

Provider Business Mailing Address
First Line	:	1225 N MOUND ST
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75961-4028
Country	:	US
Telephone Number	:	936-559-5330
Fax Number	:	936-559-7140

Provider Business Practice Location Address
First Line	:	1225 N MOUND ST
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75961-4028
Country	:	US
Telephone Number	:	936-559-5330
Fax Number	:	936-559-7140

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DYANESH BAPU G RAVINDRAN
Credential	:	M.D
Telephone Number	:	936-559-5330

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	07/30/2010

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