Provider Demographics
NPI:1831428184
Name:GERALD FANAROF, M.D., P.A.
Entity type:Organization
Organization Name:GERALD FANAROF, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:FANAROF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-589-1960
Mailing Address - Street 1:12121 RICHMOND AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082-2432
Mailing Address - Country:US
Mailing Address - Phone:281-589-1960
Mailing Address - Fax:281-589-1961
Practice Address - Street 1:12121 RICHMOND AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-2432
Practice Address - Country:US
Practice Address - Phone:281-589-1960
Practice Address - Fax:281-589-1961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-16
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0181174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033846901Medicaid
TXB22626Medicare UPIN
TX00HC30Medicare PIN