Provider Demographics
NPI:1154443471
Name:MARTIN BASALDUA MD OPTIMAL HEALTH & WELLNESS CENTER
Entity Type:Organization
Organization Name:MARTIN BASALDUA MD OPTIMAL HEALTH & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BASALDUA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-359-5749
Mailing Address - Street 1:1719 BROOKSIDE PINE LN
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77345-1909
Mailing Address - Country:US
Mailing Address - Phone:281-359-5749
Mailing Address - Fax:281-359-2089
Practice Address - Street 1:22999 HIGHWAY 59 N
Practice Address - Street 2:SUITE 270
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-4412
Practice Address - Country:US
Practice Address - Phone:281-359-5749
Practice Address - Fax:281-359-2089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8007261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB21109Medicare UPIN