Healthcare Provider Details

I. General information

NPI: 1497105084
Provider Name (Legal Business Name): UTMB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3060 FM 3514 MEDICAL DEPARTMENT - MS. ADODO
BEAUMONT TX
77705-7635
US

IV. Provider business mailing address

3060 FM 3514
BEAUMONT TX
77705-7635
US

V. Phone/Fax

Practice location:
  • Phone: 409-722-5255
  • Fax: 409-719-4157
Mailing address:
  • Phone: 409-722-5255
  • Fax: 409-719-4157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP131092
License Number StateTX

VIII. Authorized Official

Name: MARK BARBER
Title or Position: MEDICAL DIRECTOR
Credential: D.O.
Phone: 409-722-5255