Provider Demographics
NPI:1629163613
Name:FALLON, MICHAEL BROUSE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BROUSE
Last Name:FALLON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6431 FANNIN ST
Mailing Address - Street 2:MSB 4.234
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1501
Mailing Address - Country:US
Mailing Address - Phone:713-500-6671
Mailing Address - Fax:
Practice Address - Street 1:6411 FANNIN ST
Practice Address - Street 2:1 JONES SUITE 400
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1501
Practice Address - Country:US
Practice Address - Phone:713-704-6800
Practice Address - Fax:713-704-6616
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL18655207RG0100X
TXN1316207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0122311Medicaid
TX8F6668OtherBCBS
TX198331401Medicaid
AL000025081Medicaid
AL051025081OtherBLUE CROSS
MS0122311Medicaid
TX198331401Medicaid
AL051025081Medicare ID - Type Unspecified
AL000025081Medicaid