=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093235350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENDO TELEHEALTH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12518 CUTTEN RD STE B
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77066-1804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-900-9434
-----------------------------------------------------
Fax | 832-900-9452
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12518 CUTTEN RD STE B
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77066-1804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-900-9434
-----------------------------------------------------
Fax | 832-900-9452
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DAMARIS VEGA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 832-900-9434
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | M0956
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------