Provider Demographics
NPI:1578895116
Name:ID PHYSICIAN CONSULTATION SERVICE PLLC
Entity Type:Organization
Organization Name:ID PHYSICIAN CONSULTATION SERVICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MOHANAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKLEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-914-6873
Mailing Address - Street 1:716 BEDELL LN
Mailing Address - Street 2:
Mailing Address - City:MURPHY
Mailing Address - State:TX
Mailing Address - Zip Code:75094-4260
Mailing Address - Country:US
Mailing Address - Phone:214-914-6873
Mailing Address - Fax:
Practice Address - Street 1:716 BEDELL LN
Practice Address - Street 2:
Practice Address - City:MURPHY
Practice Address - State:TX
Practice Address - Zip Code:75094-4260
Practice Address - Country:US
Practice Address - Phone:214-914-6873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7840174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty