Healthcare Provider Details

I. General information

NPI: 1033421235
Provider Name (Legal Business Name): MASHHOOR BERAGDAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 UNIVERSITY BLVD DEPARTMENT OF GERIATRIC MEDICINE, MAIL ROUTE 0177
GALVESTON TX
77555-0177
US

IV. Provider business mailing address

301 UNIVERSITY BLVD DEPARTMENT OF GERIATRIC MEDICINE MAIL ROUTE 0177
GALVESTON TX
77555-0177
US

V. Phone/Fax

Practice location:
  • Phone: 409-266-9634
  • Fax: 409-747-3585
Mailing address:
  • Phone: 409-266-9634
  • Fax: 409-747-3585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberBP10036748
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: