Provider Demographics
NPI:1619183936
Name:CLEAR LAKE PEDIATRIC CLINIC, P.A.
Entity Type:Organization
Organization Name:CLEAR LAKE PEDIATRIC CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-332-4830
Mailing Address - Street 1:16 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4127
Mailing Address - Country:US
Mailing Address - Phone:281-332-3503
Mailing Address - Fax:281-332-3506
Practice Address - Street 1:16 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4127
Practice Address - Country:US
Practice Address - Phone:281-332-3503
Practice Address - Fax:281-332-3506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXN891Medicare ID - Type Unspecified