Provider Demographics
NPI:1063680619
Name:JEFFREY D RETTIG DO PA
Entity type:Organization
Organization Name:JEFFREY D RETTIG DO PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:RETTIG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:254-729-3740
Mailing Address - Street 1:PO BOX 871
Mailing Address - Street 2:
Mailing Address - City:GROESBECK
Mailing Address - State:TX
Mailing Address - Zip Code:76642-0871
Mailing Address - Country:US
Mailing Address - Phone:254-729-3740
Mailing Address - Fax:254-729-2200
Practice Address - Street 1:204 W TRINITY ST
Practice Address - Street 2:
Practice Address - City:GROESBECK
Practice Address - State:TX
Practice Address - Zip Code:76642-1324
Practice Address - Country:US
Practice Address - Phone:254-729-3740
Practice Address - Fax:254-729-2200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-18
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080994901Medicaid
TX0067CCMedicare PIN