Provider Demographics
NPI:1780639138
Name:OCCUPATIONAL AND FAMILY MEDICINE OF SOUTH TEXAS
Entity Type:Organization
Organization Name:OCCUPATIONAL AND FAMILY MEDICINE OF SOUTH TEXAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-383-9605
Mailing Address - Street 1:4001 PRESTON AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77505
Mailing Address - Country:US
Mailing Address - Phone:281-249-2273
Mailing Address - Fax:281-249-2281
Practice Address - Street 1:4001 PRESTON AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77505-2019
Practice Address - Country:US
Practice Address - Phone:281-249-2273
Practice Address - Fax:281-249-2123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181947601Medicaid
TX5914970001Medicare NSC
TX00W455Medicare PIN