Healthcare Provider Details

I. General information

NPI: 1174673685
Provider Name (Legal Business Name): JESSE WILLIAM VREDENBURGH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24624 INTERSTATE 45 N STE 125
SPRING TX
77386-4084
US

IV. Provider business mailing address

745 KINGS POINT HBR
CORPUS CHRISTI TX
78402-1713
US

V. Phone/Fax

Practice location:
  • Phone: 832-688-6111
  • Fax: 832-365-6132
Mailing address:
  • Phone: 361-563-4325
  • Fax: 361-880-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberJ1804
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberJ1804
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJ1804
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: