Provider Demographics
NPI:1124142609
Name:MOMIN, MUSTAK MANSUR (MD)
Entity type:Individual
Prefix:MR
First Name:MUSTAK
Middle Name:MANSUR
Last Name:MOMIN
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 1:13411 GOLDEN FIELD DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77059-2834
Mailing Address - Country:US
Mailing Address - Phone:281-461-4865
Mailing Address - Fax:281-461-4865
Practice Address - Street 1:908 SOUTHMORE AVE
Practice Address - Street 2:SUITE # 340
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77502-1134
Practice Address - Country:US
Practice Address - Phone:713-477-0400
Practice Address - Fax:713-477-2711
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7457208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000178Y5Medicaid
TX8620N6OtherNATIONAL PROVIDER IDENTIF
TXP000178Y5Medicaid