Provider Demographics
NPI:1982738076
Name:MACTAL, JOSEFINO M (PT)
Entity type:Individual
Prefix:
First Name:JOSEFINO
Middle Name:M
Last Name:MACTAL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5500
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75712-5500
Mailing Address - Country:US
Mailing Address - Phone:903-510-1113
Mailing Address - Fax:
Practice Address - Street 1:301 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-2471
Practice Address - Country:US
Practice Address - Phone:903-872-4611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1138626225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177899501Medicaid
TX177899501Medicaid
TXP00268714Medicare PIN
TX8G2122Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NO.