Basic Information
| Provider Information | |||||||||
| NPI: | 1295865616 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEANDA | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | CAVE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 706 TURTLE CREEK DR | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757011833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035931786 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 05/12/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | J2529 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 390200000X | BC2690003 | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 75-2616977-027 | 01 | TX | TRICARE | OTHER | 75-2616977-042 | 01 | TX | TRICARE | OTHER |