Provider Demographics
NPI:1407977960
Name:PAUL WESOLOW MD
Entity Type:Organization
Organization Name:PAUL WESOLOW MD
Other - Org Name:SOUR LAKE FAMILY MEDICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:PAUL WESOLOW MD
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:WESOLOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-287-2762
Mailing Address - Street 1:PO BOX 949
Mailing Address - Street 2:
Mailing Address - City:SOUR LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:77659
Mailing Address - Country:US
Mailing Address - Phone:409-287-2762
Mailing Address - Fax:
Practice Address - Street 1:517 S HWY 326
Practice Address - Street 2:
Practice Address - City:SOUR LAKE
Practice Address - State:TX
Practice Address - Zip Code:77659
Practice Address - Country:US
Practice Address - Phone:409-287-2762
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1812207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F28992Medicare UPIN
TXK34ZMedicare PIN