Healthcare Provider Details

I. General information

NPI: 1295317873
Provider Name (Legal Business Name): LYCA FLAKE INTAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2021
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6431 FANNIN STREET, MSB 3.151
HOUSTON TX
77030
US

IV. Provider business mailing address

6431 FANNIN STREET, MSB 3.151
HOUSTON TX
77030
US

V. Phone/Fax

Practice location:
  • Phone: 713-500-5800
  • Fax: 713-500-5805
Mailing address:
  • Phone: 713-500-5800
  • Fax: 713-500-5805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberU6731
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: