Provider Demographics
NPI:1376629964
Name:DIGESTIVE DISEASE CONSULTANTS PA
Entity Type:Organization
Organization Name:DIGESTIVE DISEASE CONSULTANTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LVN OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STARR
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:281-446-8114
Mailing Address - Street 1:9816 MEMORIAL BLVD
Mailing Address - Street 2:#206
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77338
Mailing Address - Country:US
Mailing Address - Phone:281-446-8114
Mailing Address - Fax:281-446-1158
Practice Address - Street 1:9816 MEMORIAL BLVD
Practice Address - Street 2:#206
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338
Practice Address - Country:US
Practice Address - Phone:281-446-8114
Practice Address - Fax:281-446-1158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX081671201Medicaid
TX081671201Medicaid
TX00B13GMedicare ID - Type Unspecified