Basic Information
| Provider Information | |||||||||
| NPI: | 1548250392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CECCOLI | ||||||||
| FirstName: | HECTOR | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1783 TROUP HWY | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757015869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035952283 | ||||||||
| FaxNumber: | 9035951063 | ||||||||
| Practice Location | |||||||||
| Address1: | 1783 TROUP HWY | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757015869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035952283 | ||||||||
| FaxNumber: | 9035951063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 11/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | K9749 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | P00268149 | 01 | TX | PALMETTO GBA | OTHER | 096567503 | 05 | TX | MEDICAID | 87791Y | 01 | TX | BCBS OF TEXAS | OTHER | 1635235 | 05 | LA | MEDICAID |