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General NPI Number Information
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NPI Number | 1417447012
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Entity Type | Organization
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Legal Business Name | COMPLETE INFECTIOUS DISEASES CARE ASSOCIATES, PLLC
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Dates
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Enumeration Date | 05/18/2018
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Last Update Date | 05/18/2018
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Provider Practice Location Address
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Address Line | 11803 SOUTH FWY STE 202
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City | BURLESON
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State | TX
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Zip | 76028-7029
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Country | US
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Telephone | 646-244-8857
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1841
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City | COLLEYVILLE
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State | TX
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Zip | 76034-1841
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | VITALY GOLUB
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Credential | MD
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Telephone | 646-244-8857
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | P6399
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License Number State | TX
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