Provider Demographics
NPI:1235372467
Name:CLINIC OF THE EAST END ASSOCIATION
Entity Type:Organization
Organization Name:CLINIC OF THE EAST END ASSOCIATION
Other - Org Name:EAST END MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL OFFICER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CHANDRALATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-923-6627
Mailing Address - Street 1:906 WAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77011-2518
Mailing Address - Country:US
Mailing Address - Phone:713-923-6627
Mailing Address - Fax:713-923-9383
Practice Address - Street 1:906 WAYSIDE DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77011-2518
Practice Address - Country:US
Practice Address - Phone:713-923-6627
Practice Address - Fax:713-923-9383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-17
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX214554202Medicaid
TX082252001Medicaid
TX214554201Medicaid
TX112022201Medicaid
TX8F22098Medicare PIN
TX135167808Medicaid
TX135167807Medicaid
TX112022202Medicaid