Provider Demographics
NPI:1295881142
Name:PEDROZA, SIMON V
Entity type:Individual
Prefix:MR
First Name:SIMON
Middle Name:V
Last Name:PEDROZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 PEDDIE ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008-4549
Mailing Address - Country:US
Mailing Address - Phone:713-222-6650
Mailing Address - Fax:713-225-6026
Practice Address - Street 1:3303 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77009-5637
Practice Address - Country:US
Practice Address - Phone:713-222-6650
Practice Address - Fax:713-225-6026
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18422183500000X
TX24063183500000X
TX19069183500000X
TX118736183700000X
TX118700183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist
Not Answered183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143700Medicaid
TX143700Medicaid