Provider Demographics
NPI:1699863092
Name:DEEP EAST TEXAS MATERNAL AND FAMILY HEALTH, PA
Entity type:Organization
Organization Name:DEEP EAST TEXAS MATERNAL AND FAMILY HEALTH, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:GILLILAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-384-3430
Mailing Address - Street 1:315 W HOUSTON
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:409-383-1054
Practice Address - Street 1:HWY 83 W
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951
Practice Address - Country:US
Practice Address - Phone:409-787-4765
Practice Address - Fax:409-787-4489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
458911Medicare ID - Type Unspecified