Provider Demographics
NPI:1568473767
Name:HOUSTON PRIMARY CARE, INC.
Entity Type:Organization
Organization Name:HOUSTON PRIMARY CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DINAKARA
Authorized Official - Middle Name:B
Authorized Official - Last Name:SHETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-328-0806
Mailing Address - Street 1:1719 RUSSELL PKWY STE 700
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-5765
Mailing Address - Country:US
Mailing Address - Phone:478-328-8984
Mailing Address - Fax:478-328-1393
Practice Address - Street 1:1719 RUSSELL PKWY
Practice Address - Street 2:BLDG. 700
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-5763
Practice Address - Country:US
Practice Address - Phone:478-328-0806
Practice Address - Fax:478-328-1393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042431207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000720948LMedicaid
GA000720948LMedicaid
GA11BDSRLMedicare PIN