Provider Demographics
NPI:1942670401
Name:MEDFAST PEDIATRIC & FAMILY CLINIC
Entity Type:Organization
Organization Name:MEDFAST PEDIATRIC & FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OLUBUNMI
Authorized Official - Middle Name:OLUFUNKE
Authorized Official - Last Name:KAZZIM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP- C
Authorized Official - Phone:832-847-1527
Mailing Address - Street 1:14520 OLD KATY RD, ST 109
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079
Mailing Address - Country:US
Mailing Address - Phone:832-847-1527
Mailing Address - Fax:
Practice Address - Street 1:14520 OLD KATY RD, ST 109
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079
Practice Address - Country:US
Practice Address - Phone:832-847-1527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-28
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128920363L00000X
363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty