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General NPI Number Information
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NPI Number | 1083686091
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Entity Type | Organization
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Legal Business Name | EAST HOUSTON MEDICINE & PEDIATRICS CLINIC PA
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Dates
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Enumeration Date | 02/03/2006
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Last Update Date | 09/03/2025
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Provider Practice Location Address
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Address Line | 12739 WOODFOREST BLVD STE 2
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City | HOUSTON
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State | TX
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Zip | 77015-2737
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Country | US
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Telephone | 713-450-4455
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Fax | 713-450-4737
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Provider Business Mailing Address
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Address Line | PO BOX 24308
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City | HOUSTON
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State | TX
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Zip | 77229-4308
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Country | US
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Telephone | 713-450-4455
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Fax | 713-450-4737
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Authorized Official
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Title or Position | OWNER PRESIDENT
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Name | MR. CORNELIUS ANTOINNE WILSON
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Credential | MD
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Telephone | 713-450-4455
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207RA0000X
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Taxonomy Name | Adolescent Medicine (Internal Medicine) Physician
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License Number | J2845
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License Number State | TX
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