Healthcare Provider Details

I. General information

NPI: 1770743304
Provider Name (Legal Business Name): PEDIATRIC SPECIALISTS OF CLEARLAKE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 MEDICAL CENTER BLVD STUIE 600
WEBSTER TX
77598-4234
US

IV. Provider business mailing address

450 MEDICAL CENTER BLVD STUIE 600
WEBSTER TX
77598-4234
US

V. Phone/Fax

Practice location:
  • Phone: 281-554-4300
  • Fax: 281-554-4355
Mailing address:
  • Phone: 281-554-4300
  • Fax: 281-554-4355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: TODD EVANS
Title or Position: PRESIDENT
Credential:
Phone: 713-852-1550