Provider Demographics
NPI:1760428106
Name:PODET, ETHAN J (MD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:J
Last Name:PODET
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 1:1315 ST JOSEPH PKWY STE 1605
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77002-8232
Mailing Address - Country:US
Mailing Address - Phone:713-652-3025
Mailing Address - Fax:713-652-9004
Practice Address - Street 1:1315 ST JOSEPH PKWY STE 1605
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77002-8232
Practice Address - Country:US
Practice Address - Phone:713-652-3025
Practice Address - Fax:713-652-9004
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3055207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX098272002Medicaid
TX098272001Medicaid
TX098272002Medicaid
TXE42598Medicare UPIN
TX00F49F2Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID
TX098272001Medicaid