Provider Demographics
NPI:1588655435
Name:GORDON E. CROFOOT M.D., P.A.
Entity Type:Organization
Organization Name:GORDON E. CROFOOT M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:E
Authorized Official - Last Name:CROFOOT
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:713-526-0005
Mailing Address - Street 1:3701 KIRBY DR
Mailing Address - Street 2:SUITE 1230
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77098-3900
Mailing Address - Country:US
Mailing Address - Phone:713-526-0005
Mailing Address - Fax:713-524-1602
Practice Address - Street 1:3701 KIRBY DR
Practice Address - Street 2:SUITE 1230
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77098-3900
Practice Address - Country:US
Practice Address - Phone:713-526-0005
Practice Address - Fax:713-524-1602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9592207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115207602Medicaid
TX8A9826Medicare ID - Type Unspecified
TX115207602Medicaid