Provider Demographics
NPI:1902005473
Name:BISSONNET INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:BISSONNET INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OBIAJULU
Authorized Official - Middle Name:CLETUS
Authorized Official - Last Name:EZENWABACHILI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-484-9100
Mailing Address - Street 1:7737 SOUTHWEST FWY
Mailing Address - Street 2:SUITE 620
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-1807
Mailing Address - Country:US
Mailing Address - Phone:713-484-9100
Mailing Address - Fax:713-484-7558
Practice Address - Street 1:7737 SOUTHWEST FWY
Practice Address - Street 2:SUITE 620
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1807
Practice Address - Country:US
Practice Address - Phone:713-484-9100
Practice Address - Fax:713-484-7558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0158207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00908WMedicare PIN