Provider Demographics
NPI:1407163116
Name:BRAZOSPORT WOMENS HEALTH PA
Entity Type:Organization
Organization Name:BRAZOSPORT WOMENS HEALTH PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN - OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KADIYALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-266-9544
Mailing Address - Street 1:215 OAK DRIVE SOUTH
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5617
Mailing Address - Country:US
Mailing Address - Phone:979-266-9544
Mailing Address - Fax:979-529-9737
Practice Address - Street 1:506 THIS WAY ST
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5128
Practice Address - Country:US
Practice Address - Phone:979-266-9544
Practice Address - Fax:979-529-9737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-02
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4502207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty