Provider Demographics
NPI:1376070300
Name:VAILATI NEGRAO, MARCELO VAILATI (MD)
Entity Type:Individual
Prefix:MR
First Name:MARCELO
Middle Name:VAILATI
Last Name:VAILATI NEGRAO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4439
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4439
Mailing Address - Country:US
Mailing Address - Phone:713-792-6161
Mailing Address - Fax:713-792-1220
Practice Address - Street 1:1515 HOLCOMBE BLVD
Practice Address - Street 2:UNIT 432
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:713-792-6161
Practice Address - Fax:713-792-1220
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2020-01-14
Deactivation Date:2017-12-28
Deactivation Code:
Reactivation Date:2019-08-06
Provider Licenses
StateLicense IDTaxonomies
TX46778207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX403686501Medicaid
TX403686502OtherCSHCN