Provider Demographics
NPI:1285071977
Name:FAMILY MEDICINE OF EAST TEXAS, PA
Entity type:Organization
Organization Name:FAMILY MEDICINE OF EAST TEXAS, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAFERNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-634-3396
Mailing Address - Street 1:206 GENE SAMFORD DR.
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904
Mailing Address - Country:US
Mailing Address - Phone:936-634-3396
Mailing Address - Fax:936-632-7933
Practice Address - Street 1:206 GENE SAMFORD DR.
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904
Practice Address - Country:US
Practice Address - Phone:936-634-3396
Practice Address - Fax:936-632-7933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-04
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
TXP0596261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty