Healthcare Provider Details

I. General information

NPI: 1184280695
Provider Name (Legal Business Name): ODR PEDIATRIC UROLOGY INSTITUTE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2019
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 BINZ ST STE 690
HOUSTON TX
77004-6943
US

IV. Provider business mailing address

1200 BINZ ST STE 690
HOUSTON TX
77004-6943
US

V. Phone/Fax

Practice location:
  • Phone: 713-366-7931
  • Fax: 713-482-5815
Mailing address:
  • Phone: 713-366-7931
  • Fax: 713-482-5815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State

VIII. Authorized Official

Name: DUNG Q PHAM
Title or Position: OWNER
Credential: MD
Phone: 713-366-7831