Provider Demographics
NPI:1730378449
Name:EAST TEXAS MINIMALLY INVA MICRO NS
Entity type:Organization
Organization Name:EAST TEXAS MINIMALLY INVA MICRO NS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:M
Authorized Official - Last Name:TIVIDAD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:903-238-8110
Mailing Address - Street 1:703 E MARSHALL AVE
Mailing Address - Street 2:SUITE 3004
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5500
Mailing Address - Country:US
Mailing Address - Phone:903-238-8110
Mailing Address - Fax:903-238-8190
Practice Address - Street 1:703 E MARSHALL AVE
Practice Address - Street 2:SUITE 3004
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5500
Practice Address - Country:US
Practice Address - Phone:903-238-8110
Practice Address - Fax:903-238-8190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00141RMedicare PIN