Healthcare Provider Details

I. General information

NPI: 1427419167
Provider Name (Legal Business Name): DYNAMIC SPORTS MEDICINE AND PAIN SOLUTIONS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7830 W GRAND PKWY S SUITE 150
RICHMOND TX
77406-5816
US

IV. Provider business mailing address

41922 N MILL DR
MAGNOLIA TX
77354-1850
US

V. Phone/Fax

Practice location:
  • Phone: 832-302-6212
  • Fax:
Mailing address:
  • Phone: 210-602-5578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberQ0169
License Number StateTX

VIII. Authorized Official

Name: MICAL SAMUELSON DUVALL
Title or Position: PRESIDENT
Credential: MD
Phone: 210-602-5578