Healthcare Provider Details

I. General information

NPI: 1295298578
Provider Name (Legal Business Name): NASA PEDIATRICS TEXAS CITY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

926 14TH ST N STE A
TEXAS CITY TX
77590-8902
US

IV. Provider business mailing address

PO BOX 890004
HOUSTON TX
77289-0004
US

V. Phone/Fax

Practice location:
  • Phone: 409-229-7487
  • Fax: 831-831-8623
Mailing address:
  • Phone: 713-239-0980
  • Fax: 832-831-8623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: IDALIA RIVERA-MATOS
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 713-239-0980