Provider Demographics
NPI:1639114762
Name:INGRAHAM, ANNETTE B (MD)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:B
Last Name:INGRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4301
Mailing Address - Country:US
Mailing Address - Phone:281-212-2400
Mailing Address - Fax:281-212-2499
Practice Address - Street 1:150 E MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4301
Practice Address - Country:US
Practice Address - Phone:281-212-2400
Practice Address - Fax:281-212-2499
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0012208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129469607Medicaid
TX129469607Medicaid
8A1928Medicare ID - Type Unspecified