Healthcare Provider Details

I. General information

NPI: 1770677130
Provider Name (Legal Business Name): MEDICAL INFECTIOUS DISEASE CONSULTING SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18951 N MEMORIAL
HUMBLE TX
77338-4217
US

IV. Provider business mailing address

PO BOX 131224
THE WOODLANDS TX
77393
US

V. Phone/Fax

Practice location:
  • Phone: 281-540-7700
  • Fax:
Mailing address:
  • Phone: 281-893-4376
  • Fax: 281-419-6362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberE7377
License Number StateTX

VIII. Authorized Official

Name: RICARDO BOLIVAR
Title or Position: PRESIDENT
Credential: MD
Phone: 281-893-4376