Provider Demographics
NPI:1689496812
Name:UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT TYLER-FACILTY-PHYSICIAN
Entity type:Organization
Organization Name:UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT TYLER-FACILTY-PHYSICIAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF BUSINESS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DESLATTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-877-7200
Mailing Address - Street 1:11937 US HIGHWAY 271
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75708-3154
Mailing Address - Country:US
Mailing Address - Phone:903-877-7200
Mailing Address - Fax:
Practice Address - Street 1:102 W HENDERSON ST
Practice Address - Street 2:
Practice Address - City:OVERTON
Practice Address - State:TX
Practice Address - Zip Code:75684-1613
Practice Address - Country:US
Practice Address - Phone:903-834-0201
Practice Address - Fax:903-834-0264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-29
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health