Provider Demographics
NPI:1750091245
Name:LUSAMBA, JOSEPHINE IV (MD)
Entity type:Individual
Prefix:MISS
First Name:JOSEPHINE
Middle Name:
Last Name:LUSAMBA
Suffix:IV
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12337 JONES RD STE 200-12
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4893
Mailing Address - Country:US
Mailing Address - Phone:903-345-4545
Mailing Address - Fax:
Practice Address - Street 1:12337 JONES RD STE 200-12
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4893
Practice Address - Country:US
Practice Address - Phone:903-345-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-25
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXEIN-842992016Medicaid