Provider Demographics
NPI:1225562887
Name:VASU MEDICAL PLLC
Entity Type:Organization
Organization Name:VASU MEDICAL PLLC
Other - Org Name:CLEAR LAKE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHUKLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-306-1509
Mailing Address - Street 1:450 W MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4234
Mailing Address - Country:US
Mailing Address - Phone:832-906-2500
Mailing Address - Fax:832-906-2501
Practice Address - Street 1:450 W MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4234
Practice Address - Country:US
Practice Address - Phone:832-906-2500
Practice Address - Fax:832-906-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-19
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9300261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1100074811Medicare NSC