Provider Demographics
NPI:1346363587
Name:MT HOUSTON MEDICAL CLINIC
Entity Type:Organization
Organization Name:MT HOUSTON MEDICAL CLINIC
Other - Org Name:HUI JUN PARK, DC PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMIN/CREDENTIALING SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SHIRAH
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:832-683-4132
Mailing Address - Street 1:11703A EASTEX FWY
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77039-6205
Mailing Address - Country:US
Mailing Address - Phone:832-683-4132
Mailing Address - Fax:832-683-4133
Practice Address - Street 1:11703A EASTEX FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77039-6205
Practice Address - Country:US
Practice Address - Phone:832-683-4132
Practice Address - Fax:832-683-4133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8017174400000X
TXAP126718363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0078GFOtherBCBS GRP ID