Provider Demographics
NPI:1235795535
Name:DEER PARK PHYSICIAN GROUP PLLC
Entity Type:Organization
Organization Name:DEER PARK PHYSICIAN GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RADHESHYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRYALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:346-954-6007
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77383-0520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 EAST BLVD
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:TX
Practice Address - Zip Code:77536-1909
Practice Address - Country:US
Practice Address - Phone:346-954-6007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-13
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty