Provider Demographics
NPI:1619199619
Name:MUILENBURG, TED B
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:B
Last Name:MUILENBURG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 LA BRANCH ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-4046
Mailing Address - Country:US
Mailing Address - Phone:713-524-3949
Mailing Address - Fax:713-524-3915
Practice Address - Street 1:3900 LA BRANCH ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-4046
Practice Address - Country:US
Practice Address - Phone:713-524-3949
Practice Address - Fax:713-524-3915
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX407224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX086146001Medicaid
TX086146001Medicaid