Provider Demographics
NPI:1407133036
Name:RAFAEL E. VALENZUELA, M.D.P.A.
Entity Type:Organization
Organization Name:RAFAEL E. VALENZUELA, M.D.P.A.
Other - Org Name:EDWARD INDUSTRIAL MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:ERNESTO
Authorized Official - Last Name:VALENZUELA
Authorized Official - Suffix:
Authorized Official - Credentials:F7938
Authorized Official - Phone:713-691-0035
Mailing Address - Street 1:720 E TIDWELL RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77022-1822
Mailing Address - Country:US
Mailing Address - Phone:713-691-0035
Mailing Address - Fax:713-691-2448
Practice Address - Street 1:720 E TIDWELL RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77022-1822
Practice Address - Country:US
Practice Address - Phone:713-691-0035
Practice Address - Fax:713-691-2448
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RAFAEL E. VALENZUELA, M.D.P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-10
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7948305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091998701Medicaid
TX091998701Medicaid