Provider Demographics
NPI:1114288552
Name:FONDREN MD CENTER LLC
Entity Type:Organization
Organization Name:FONDREN MD CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:VALI OGLY
Authorized Official - Last Name:GAZRATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-541-0100
Mailing Address - Street 1:10101 FONDREN RD
Mailing Address - Street 2:STE 128
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77096-4564
Mailing Address - Country:US
Mailing Address - Phone:713-541-0100
Mailing Address - Fax:713-541-0105
Practice Address - Street 1:10101 FONDREN RD
Practice Address - Street 2:STE 128
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77096-4564
Practice Address - Country:US
Practice Address - Phone:713-541-0100
Practice Address - Fax:713-541-0105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty