Basic Information
| Provider Information | |||||||||
| NPI: | 1811048697 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FLASKAS | ||||||||
| FirstName: | MARINA | ||||||||
| MiddleName: | YURIEVNA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 703 S FLEISHEL AVE | ||||||||
| Address2: | STE 4000 | ||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036067000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 10/13/2014 | ||||||||
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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 | 207RC0000X | N1319 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 23208 | WV | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X | 23208 | WV | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 198507901 | 05 | TX | MEDICAID | 75-2616977-019 | 01 | TX | TRICARE | OTHER | 75-0818167-015 | 01 | TX | TRICARE | OTHER | 8BC261 | 01 | TX | BCBS OF TEXAS | OTHER | 198507902 | 05 | TX | MEDICAID | TIN PLUS 001 | 01 | TX | TRICARE | OTHER | 8ED335 | 01 | TX | BCBS | OTHER | TIN PLUS 029 | 01 | TX | TRICARE | OTHER | TIN PLUS 042 | 01 | TX | TRICARE | OTHER |