Provider Demographics
NPI:1245565985
Name:HOUSTON OB/GYN, LLC
Entity Type:Organization
Organization Name:HOUSTON OB/GYN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CARLO
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-923-6462
Mailing Address - Street 1:PO BOX 2426
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31099-2426
Mailing Address - Country:US
Mailing Address - Phone:478-923-6462
Mailing Address - Fax:478-923-6215
Practice Address - Street 1:1570 WATSON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3432
Practice Address - Country:US
Practice Address - Phone:478-923-6462
Practice Address - Fax:478-923-6215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-14
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041455207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000725029IMedicaid
GA000725029EMedicaid
GAG39361Medicare UPIN
GA000725029IMedicaid
GA202G703838Medicare PIN