Provider Demographics
NPI:1215152251
Name:EAST TEXAS PLASTIC SURGERY LLP
Entity type:Organization
Organization Name:EAST TEXAS PLASTIC SURGERY LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-753-2276
Mailing Address - Street 1:703 E MARSHALL AVE STE 4008
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5622
Mailing Address - Country:US
Mailing Address - Phone:903-753-2276
Mailing Address - Fax:903-753-7420
Practice Address - Street 1:703 E MARSHALL AVE STE 4008
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5622
Practice Address - Country:US
Practice Address - Phone:903-753-2276
Practice Address - Fax:903-753-7420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE44272086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110309502Medicaid
TX86Y711Medicare ID - Type Unspecified
TX110309502Medicaid
TX045323501Medicaid
TXF47944Medicare UPIN
TX110309502Medicaid