Provider Demographics
NPI:1770918013
Name:MOHAMED D VADVA MD PA
Entity type:Organization
Organization Name:MOHAMED D VADVA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:DAWOOD
Authorized Official - Last Name:VADVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-722-7700
Mailing Address - Street 1:2501 JIMMY JOHNSON BLVD
Mailing Address - Street 2:SIUTE 204
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77640-2000
Mailing Address - Country:US
Mailing Address - Phone:409-722-7700
Mailing Address - Fax:409-722-7705
Practice Address - Street 1:2501 JIMMY JOHNSON BLVD
Practice Address - Street 2:SIUTE 204
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640-2000
Practice Address - Country:US
Practice Address - Phone:409-722-7700
Practice Address - Fax:409-722-7705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5042207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty