Healthcare Provider Details

I. General information

NPI: 1487945879
Provider Name (Legal Business Name): MENNEN T. GALLAS, MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2011
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21300 PROVINCIAL BLVD
KATY TX
77450-7580
US

IV. Provider business mailing address

21300 PROVINCIAL BLVD
KATY TX
77450-7580
US

V. Phone/Fax

Practice location:
  • Phone: 281-646-1114
  • Fax: 281-646-1138
Mailing address:
  • Phone: 281-646-1114
  • Fax: 281-646-1138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberK5105
License Number StateTX

VIII. Authorized Official

Name: DR. MENNEN THEODORE GALLAS
Title or Position: OWNER
Credential: M.D.
Phone: 281-646-1114