Provider Demographics
NPI:1225118649
Name:PRICE, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:PRICE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6621 FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2303
Mailing Address - Country:US
Mailing Address - Phone:832-826-5664
Mailing Address - Fax:832-825-1906
Practice Address - Street 1:6621 FANNIN ST
Practice Address - Street 2:MC19345-C
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2303
Practice Address - Country:US
Practice Address - Phone:832-826-5664
Practice Address - Fax:832-825-1906
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL65862080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149794301Medicaid
8677N3Medicare ID - Type Unspecified
H57059Medicare UPIN