Provider Demographics
NPI:1427541101
Name:INNOVATIVE ALLERGY
Entity Type:Organization
Organization Name:INNOVATIVE ALLERGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAT
Authorized Official - Middle Name:QUOC
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-701-5457
Mailing Address - Street 1:5001 BISSONNET ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-4023
Mailing Address - Country:US
Mailing Address - Phone:281-701-5457
Mailing Address - Fax:281-605-6815
Practice Address - Street 1:5001 BISSONNET ST STE 200
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-4023
Practice Address - Country:US
Practice Address - Phone:281-701-5457
Practice Address - Fax:281-605-6815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-07
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4167207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX453533520Medicaid