Healthcare Provider Details

I. General information

NPI: 1306953716
Provider Name (Legal Business Name): MAHFOUDH BEN BEAOUI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S. ROSS STERLING
ANAHUAC TX
77514-0398
US

IV. Provider business mailing address

621 SOUTH ROSS STERLING
ANAHUAC TX
77514-0398
US

V. Phone/Fax

Practice location:
  • Phone: 409-267-3143
  • Fax: 409-267-4443
Mailing address:
  • Phone: 409-267-3143
  • Fax: 409-267-4443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01500
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: