Provider Demographics
NPI:1578753265
Name:BADLISSI, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:BADLISSI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 HIGHWAY 365 STE 205
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-6250
Mailing Address - Country:US
Mailing Address - Phone:409-722-1197
Mailing Address - Fax:
Practice Address - Street 1:2400 HIGHWAY 365
Practice Address - Street 2:STE 205
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627-6249
Practice Address - Country:US
Practice Address - Phone:409-722-1197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-28
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0620207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB145670Medicare PIN