Provider Demographics
NPI:1083686091
Name:EAST HOUSTON MEDICINE & PEDIATRICS CLINIC PA
Entity Type:Organization
Organization Name:EAST HOUSTON MEDICINE & PEDIATRICS CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CORNELIUS
Authorized Official - Middle Name:ANTOINNE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-450-4455
Mailing Address - Street 1:PO BOX 24308
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77229-4308
Mailing Address - Country:US
Mailing Address - Phone:713-450-4455
Mailing Address - Fax:713-450-4737
Practice Address - Street 1:902 NORMANDY ST
Practice Address - Street 2:STE 100
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-4952
Practice Address - Country:US
Practice Address - Phone:713-450-4455
Practice Address - Fax:713-450-4737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-03
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
TXJ2845207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0081QDOtherBLUE CROSS
TX00L66JOtherBCBS
TX184593501Medicaid
TX45D1000292OtherCLIA
TX184593502Medicaid
TX00426XMedicare PIN