MEDICARE: CHRISTUS MEDICAL GROUP OBSTETRICS AND GYNECOLOGY ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1467471599
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRISTUS MEDICAL GROUP OBSTETRICS AND GYNECOLOGY ASSOCIATES

Provider Business Mailing Address
First Line	:	1311 EAST GENERAL VAVAZOS BLVD.
Second Line	:
City	:	KINGSVILLE
State	:	TX
Zip	:	78363
Country	:	US
Telephone Number	:	361-595-9900
Fax Number	:

Provider Business Practice Location Address
First Line	:	1311 EAST GENERAL VAVAZOS BLVD.
Second Line	:
City	:	KINGSVILLE
State	:	TX
Zip	:	78363
Country	:	US
Telephone Number	:	361-595-9900
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MRS. DONNA MIKULECKY
Credential	:
Telephone Number	:	713-812-6891

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	08/22/2020

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