Provider Demographics
NPI:1811486814
Name:CYPRESS CREEK PEDIATRIC CLINIC
Entity type:Organization
Organization Name:CYPRESS CREEK PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:NALINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANDRASEKHARAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-444-0000
Mailing Address - Street 1:4560 CYPRESS CREEK PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77069-4628
Mailing Address - Country:US
Mailing Address - Phone:281-444-0000
Mailing Address - Fax:281-444-6158
Practice Address - Street 1:4560 CYPRESS CREEK PKWY STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77069-4628
Practice Address - Country:US
Practice Address - Phone:281-444-0000
Practice Address - Fax:281-444-6158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-04
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ1802208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1104967025Medicaid