Provider Demographics
NPI:1962525477
Name:NORTHEAST TEXAS ORTHOPAEDIC SPCECIALISTS PA
Entity type:Organization
Organization Name:NORTHEAST TEXAS ORTHOPAEDIC SPCECIALISTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:LATHAM
Authorized Official - Last Name:WALDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-983-2556
Mailing Address - Street 1:1718 S HENDERSON BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-3566
Mailing Address - Country:US
Mailing Address - Phone:903-983-2556
Mailing Address - Fax:903-983-3115
Practice Address - Street 1:1718 S HENDERSON BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3566
Practice Address - Country:US
Practice Address - Phone:903-983-2556
Practice Address - Fax:903-983-3115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU39ZMedicare ID - Type Unspecified