Provider Demographics
NPI:1952601122
Name:CLOS, AUDRA L (MD)
Entity Type:Individual
Prefix:DR
First Name:AUDRA
Middle Name:L
Last Name:CLOS
Suffix:
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 1:5280 CAROLINE ST APT 2303
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-5887
Mailing Address - Country:US
Mailing Address - Phone:832-746-1402
Mailing Address - Fax:
Practice Address - Street 1:20320 NORTHWEST FWY STE 700
Practice Address - Street 2:
Practice Address - City:JERSEY VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:77065-5645
Practice Address - Country:US
Practice Address - Phone:346-437-0400
Practice Address - Fax:346-437-0404
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP0361207R00000X, 207N00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201410050Medicaid
TX413430YME1Medicare UPIN
IN201410050Medicaid
TX413430YLUVMedicare UPIN
IN132590014Medicare PIN