Provider Demographics
NPI:1841248630
Name:NACOGDOCHES MEDICAL CLINIC PLLC
Entity type:Organization
Organization Name:NACOGDOCHES MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAVITA
Authorized Official - Middle Name:S
Authorized Official - Last Name:VYAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-560-2920
Mailing Address - Street 1:607 RUSSELL BLVD
Mailing Address - Street 2:A
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1247
Mailing Address - Country:US
Mailing Address - Phone:936-560-2920
Mailing Address - Fax:866-861-6312
Practice Address - Street 1:607 RUSSELL BLVD
Practice Address - Street 2:A
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1247
Practice Address - Country:US
Practice Address - Phone:936-560-2920
Practice Address - Fax:866-861-6312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
TXK9697207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX079792001Medicaid
TX00079FMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER