Provider Demographics
NPI:1114044328
Name:PULMONARY DISEASES MEDICINE CLINIC
Entity type:Organization
Organization Name:PULMONARY DISEASES MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-792-3660
Mailing Address - Street 1:921 TEXAS BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-5163
Mailing Address - Country:US
Mailing Address - Phone:903-792-3660
Mailing Address - Fax:903-793-3187
Practice Address - Street 1:921 TEXAS BLVD STE D
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-5163
Practice Address - Country:US
Practice Address - Phone:903-792-3660
Practice Address - Fax:903-793-3187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR90815000040OtherQUAL CHOICE
TX0055ROtherTX BCBS
AR8P083OtherAR BCBS
TX1415531 01Medicaid
OK200092730AOtherOK CAID
TXDA7905OtherRR MEDICARE
TX1415531 01Medicaid