Provider Demographics
NPI:1538658422
Name:MEN AND WOMENS VITALITY CENTER PLLC
Entity Type:Organization
Organization Name:MEN AND WOMENS VITALITY CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHSIN
Authorized Official - Middle Name:
Authorized Official - Last Name:QAYYUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-327-8029
Mailing Address - Street 1:PO BOX 799
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77549-0799
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:308 S FRIENDSWOOD DR STE 110
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-3989
Practice Address - Country:US
Practice Address - Phone:281-993-3733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2195207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX214325703Medicaid