Provider Demographics
NPI:1427013978
Name:NORTHWEST INFECTIOUS DISEASE AND TRAVEL MEDICINE, PA
Entity Type:Organization
Organization Name:NORTHWEST INFECTIOUS DISEASE AND TRAVEL MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PORNTHEP
Authorized Official - Middle Name:
Authorized Official - Last Name:WATTANAMANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-384-3229
Mailing Address - Street 1:5509 CORNISH ST.
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-4303
Mailing Address - Country:US
Mailing Address - Phone:832-831-5089
Mailing Address - Fax:713-360-7715
Practice Address - Street 1:5509 CORNISH ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77007-4303
Practice Address - Country:US
Practice Address - Phone:832-831-5089
Practice Address - Fax:713-360-7715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5950207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDC8420OtherMEDICARE RAILROAD
TX0097LZOtherBLUE CROSS BLUE SHIELDS
TX171630001Medicaid