Provider Demographics
NPI: | 1417043795 |
---|---|
Name: | ISAAC, GERALD WESLEY JR (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | GERALD |
Middle Name: | WESLEY |
Last Name: | ISAAC |
Suffix: | JR |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 11511 SHADOW CREEK PKWY |
Mailing Address - Street 2: | |
Mailing Address - City: | PEARLAND |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 77584-7298 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 713-442-0000 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 5001 E SAM HOUSTON PKWY S |
Practice Address - Street 2: | |
Practice Address - City: | PASADENA |
Practice Address - State: | TX |
Practice Address - Zip Code: | 77505-3965 |
Practice Address - Country: | US |
Practice Address - Phone: | 713-442-7100 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-10-05 |
Last Update Date: | 2021-06-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | H5456 | 207R00000X, 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 136669208 | Medicaid | |
TX | 136669211 | Medicaid | |
TX | 136669212 | Medicaid | |
TX | 85J152 | Medicare PIN | |
TX | TXB112276 | Medicare PIN | |
TX | 136669208 | Medicaid | |
TX | 8B5680 | Medicare PIN | |
TX | 85J152 | Medicare PIN |