Healthcare Provider Details

I. General information

NPI: 1124142609
Provider Name (Legal Business Name): MUSTAK MANSUR MOMIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 SOUTHMORE AVE SUITE # 340
PASADENA TX
77502-1134
US

IV. Provider business mailing address

13411 GOLDEN FIELD DR
HOUSTON TX
77059-2834
US

V. Phone/Fax

Practice location:
  • Phone: 713-477-0400
  • Fax: 713-477-2711
Mailing address:
  • Phone: 281-461-4865
  • Fax: 281-461-4865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberK7457
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: