Provider Demographics
NPI:1407197247
Name:FUQUA FAMILY PRACTICE AND URGENT CARE PA
Entity Type:Organization
Organization Name:FUQUA FAMILY PRACTICE AND URGENT CARE PA
Other - Org Name:FUQUA FAMILY PRACTICE AND URGENT CARE PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JARROD
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:DRAB
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:713-941-1566
Mailing Address - Street 1:10655 FUQUA ST # C
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-2403
Mailing Address - Country:US
Mailing Address - Phone:713-941-1566
Mailing Address - Fax:713-941-1577
Practice Address - Street 1:10655 FUQUA ST # C
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-2403
Practice Address - Country:US
Practice Address - Phone:713-941-1566
Practice Address - Fax:713-941-1577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-04
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP3880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX268105OtherMEDICARE PTAN