Provider Demographics
NPI:1770743304
Name:PEDIATRIC SPECIALISTS OF CLEARLAKE PLLC
Entity type:Organization
Organization Name:PEDIATRIC SPECIALISTS OF CLEARLAKE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-852-1550
Mailing Address - Street 1:450 MEDICAL CENTER BLVD
Mailing Address - Street 2:STUIE 600
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4234
Mailing Address - Country:US
Mailing Address - Phone:281-554-4300
Mailing Address - Fax:281-554-4355
Practice Address - Street 1:450 MEDICAL CENTER BLVD
Practice Address - Street 2:STUIE 600
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4234
Practice Address - Country:US
Practice Address - Phone:281-554-4300
Practice Address - Fax:281-554-4355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-17
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196271401Medicaid
TX196271401Medicaid