Provider Demographics
NPI:1598347890
Name:MDA DIVERSIFIED ENTERPRISES CORP
Entity Type:Organization
Organization Name:MDA DIVERSIFIED ENTERPRISES CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIAL/BILLER
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-556-1298
Mailing Address - Street 1:21013 OLD SORTERS RD STE E
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:TX
Mailing Address - Zip Code:77365-7083
Mailing Address - Country:US
Mailing Address - Phone:281-381-6190
Mailing Address - Fax:
Practice Address - Street 1:23527 FM 1314 RD STE E
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:TX
Practice Address - Zip Code:77365-3724
Practice Address - Country:US
Practice Address - Phone:281-381-6190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty