Healthcare Provider Details

I. General information

NPI: 1124488085
Provider Name (Legal Business Name): BIRD DOG PHARMA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2016
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12242 QUEENSTON BLVD STE E
HOUSTON TX
77095-5353
US

IV. Provider business mailing address

12242 QUEENSTON BLVD STE E
HOUSTON TX
77095-5353
US

V. Phone/Fax

Practice location:
  • Phone: 713-252-3579
  • Fax: 800-434-7514
Mailing address:
  • Phone: 713-252-3579
  • Fax: 800-434-7514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHNNY GILBERT
Title or Position: CEO
Credential:
Phone: 713-252-3579