Provider Demographics
NPI:1144266628
Name:DENTON COLON AND RECTAL SURGERY, P.A.
Entity type:Organization
Organization Name:DENTON COLON AND RECTAL SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:PROVOST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-383-2424
Mailing Address - Street 1:1300 FULTON ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-2688
Mailing Address - Country:US
Mailing Address - Phone:940-383-2424
Mailing Address - Fax:940-387-5676
Practice Address - Street 1:1300 FULTON ST
Practice Address - Street 2:SUITE 203
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-2688
Practice Address - Country:US
Practice Address - Phone:940-383-2424
Practice Address - Fax:940-387-5676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2618208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00W619Medicare PIN