1356524862 NPI number — STASHA GOMINAK, MD, PA

Table of content: (NPI 1356524862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356524862 NPI number — STASHA GOMINAK, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STASHA GOMINAK, MD, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356524862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 OLYMPIC PLAZA CIR
Provider Second Line Business Mailing Address:
912
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75701-1951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-596-3808
Provider Business Mailing Address Fax Number:
903-596-3815

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 OLYMPIC PLAZA CIR
Provider Second Line Business Practice Location Address:
SUITE 912
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75701-1951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-596-3808
Provider Business Practice Location Address Fax Number:
903-596-3815
Provider Enumeration Date:
12/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOMINAK
Authorized Official First Name:
STASHA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
903-596-3808

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0086KV . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: DB5632 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 164213401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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