MEDICARE: MR. MUSTAK MANSUR MOMIN 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	208000000X	Pediatrics Physician	K7457	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	8620N6	OTHER	TX	NATIONAL PROVIDER IDENTIF

General Provider Information

NPI Number	:	1124142609
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MUSTAK MANSUR MOMIN M.D.

Provider Business Mailing Address
First Line	:	13411 GOLDEN FIELD DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77059-2834
Country	:	US
Telephone Number	:	281-461-4865
Fax Number	:	281-461-4865

Provider Business Practice Location Address
First Line	:	908 SOUTHMORE AVE
Second Line	:	SUITE # 340
City	:	PASADENA
State	:	TX
Zip	:	77502-1134
Country	:	US
Telephone Number	:	713-477-0400
Fax Number	:	713-477-2711

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

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	07/08/2007

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