Healthcare Provider Details

I. General information

NPI: 1407977960
Provider Name (Legal Business Name): PAUL WESOLOW MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 S HWY 326
SOUR LAKE TX
77659
US

IV. Provider business mailing address

PO BOX 949
SOUR LAKE TX
77659
US

V. Phone/Fax

Practice location:
  • Phone: 409-287-2762
  • Fax:
Mailing address:
  • Phone: 409-287-2762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJ1812
License Number StateTX

VIII. Authorized Official

Name: PAUL WESOLOW
Title or Position: PAUL WESOLOW MD
Credential: MD
Phone: 409-287-2762