Provider Demographics
NPI:1033661715
Name:SPACE CENTER PRIMARY CARE, PLLC
Entity Type:Organization
Organization Name:SPACE CENTER PRIMARY CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DERAN
Authorized Official - Middle Name:Y
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-286-6000
Mailing Address - Street 1:907 BAY AREA BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-2665
Mailing Address - Country:US
Mailing Address - Phone:281-286-6000
Mailing Address - Fax:281-488-8686
Practice Address - Street 1:907 BAY AREA BLVD STE B
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2665
Practice Address - Country:US
Practice Address - Phone:281-286-6000
Practice Address - Fax:281-488-8686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ4875261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX454495ZRZOtherMEDICARE ID