Healthcare Provider Details

I. General information

NPI: 1083447999
Provider Name (Legal Business Name): KAROL JASMIN HUANCA BERNAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 08/26/2024
Certification Date: 08/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6431 FANNIN ST
HOUSTON TX
77030-1501
US

IV. Provider business mailing address

1911 HOLCOMBE BLVD APT 1904
HOUSTON TX
77030-4193
US

V. Phone/Fax

Practice location:
  • Phone: 713-704-4000
  • Fax:
Mailing address:
  • Phone: 832-322-5594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberBP10086796
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: