Provider Demographics
NPI:1700064292
Name:PEDIATRIC CLINIC OF LAPORTE
Entity Type:Organization
Organization Name:PEDIATRIC CLINIC OF LAPORTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RAHMAN
Authorized Official - Middle Name:SAHADAT
Authorized Official - Last Name:UDDIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-867-0291
Mailing Address - Street 1:PO BOX 178
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:TX
Mailing Address - Zip Code:77572
Mailing Address - Country:US
Mailing Address - Phone:281-867-0291
Mailing Address - Fax:281-867-0292
Practice Address - Street 1:10407 WEST FAIRMONT PARKWAY
Practice Address - Street 2:SUITE B
Practice Address - City:LAPORTE
Practice Address - State:TX
Practice Address - Zip Code:77571
Practice Address - Country:US
Practice Address - Phone:281-867-0291
Practice Address - Fax:281-867-0292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9442208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX004196Medicare PIN
TXH12381Medicare UPIN