Provider Demographics
NPI:1013998673
Name:BRAZOSPORT EAR, NOSE & THROAT CLINIC, PA
Entity type:Organization
Organization Name:BRAZOSPORT EAR, NOSE & THROAT CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MEYERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-297-2477
Mailing Address - Street 1:201 OAK DR S
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5676
Mailing Address - Country:US
Mailing Address - Phone:979-297-2477
Mailing Address - Fax:
Practice Address - Street 1:201 OAK DR S
Practice Address - Street 2:SUITE 207
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5676
Practice Address - Country:US
Practice Address - Phone:979-297-2477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1152174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00K23VMedicare ID - Type Unspecified