Provider Demographics
NPI:1205085164
Name:DR. HAMID REZA JALALI, D.O., P.A.
Entity type:Organization
Organization Name:DR. HAMID REZA JALALI, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HAMID
Authorized Official - Middle Name:REZA
Authorized Official - Last Name:JALALI
Authorized Official - Suffix:
Authorized Official - Credentials:DO, PA
Authorized Official - Phone:409-745-4421
Mailing Address - Street 1:PO BOX 966
Mailing Address - Street 2:
Mailing Address - City:MAURICEVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77626-0966
Mailing Address - Country:US
Mailing Address - Phone:409-745-4421
Mailing Address - Fax:
Practice Address - Street 1:11946 HWY 62 NORTH
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77632
Practice Address - Country:US
Practice Address - Phone:409-745-4421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0491208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122951002Medicaid
TXPENDINGMedicare PIN