Healthcare Provider Details

I. General information

NPI: 1619183936
Provider Name (Legal Business Name): CLEAR LAKE PEDIATRIC CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 PROFESSIONAL PARK DR
WEBSTER TX
77598-4127
US

IV. Provider business mailing address

16 PROFESSIONAL PARK DR
WEBSTER TX
77598-4127
US

V. Phone/Fax

Practice location:
  • Phone: 281-332-3503
  • Fax: 201-849-7650
Mailing address:
  • Phone: 281-332-3503
  • Fax: 201-849-7650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MICHELLE M COOK
Title or Position: BUSINESS MANAGER
Credential:
Phone: 281-332-4830