Provider Demographics
NPI:1578077871
Name:MD MEDICAL MANAGEMENT LLC
Entity Type:Organization
Organization Name:MD MEDICAL MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:OFFICE
Authorized Official - Middle Name:
Authorized Official - Last Name:CREDENTIALIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-623-5583
Mailing Address - Street 1:1140 WESTMONT DR STE 515
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77015-4365
Mailing Address - Country:US
Mailing Address - Phone:832-623-5583
Mailing Address - Fax:832-623-6939
Practice Address - Street 1:1140 WESTMONT DR STE 515
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-4365
Practice Address - Country:US
Practice Address - Phone:832-623-5583
Practice Address - Fax:832-802-6171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-22
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3003208D00000X
207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Multi-Specialty
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty