| Organization Name: | EAST TEXAS MEDICAL CLINIC,P.A |
| NPI Number: | 1255729323 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | AJITHA CHANDRAMOHAN (MEDICAL DIRECTOR) |
| Mailing Address: | 1743 Southview Cir Center |
| State: | TX US |
| Postal Code: | 759359324 |
| Phone Number: | 9365918888 |
| Fax Number: | 9365918884 |
| NPI Enumeration Date: | 12/24/2014 |
| NPI Last Update Date: | 12/24/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | K7000 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | TX |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |