=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790102994
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDLOSS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2014
-----------------------------------------------------
Last Update Date | 03/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6910 BELLAIRE BLVD BLDG STE 8
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77074-3509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-780-8367
-----------------------------------------------------
Fax | 713-772-5841
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6910 BELLAIRE BLVD BLDG STE 8
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77074-3509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-780-8367
-----------------------------------------------------
Fax | 713-772-5841
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GILBERT MAYORGA JR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 713-772-5840
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | H3117
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------