MEDICARE: DR. LARA SELTZ MATHESON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	R6240	TX

General Provider Information

NPI Number	:	1114360450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARA SELTZ MATHESON M.D.

Provider Business Mailing Address
First Line	:	6560 FANNIN ST STE 1440
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-2713
Country	:	US
Telephone Number	:	713-790-9779
Fax Number	:	713-790-1328

Provider Business Practice Location Address
First Line	:	6560 FANNIN ST STE 1440
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-2713
Country	:	US
Telephone Number	:	713-790-9700
Fax Number	:	790-790-1328

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2013
Last Update Date	:	12/08/2020

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