MEDICARE: NORTHWEST INFECTIOUS DISEASE AND TRAVEL MEDICINE, PA

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	207RI0200X	Infectious Disease Physician	L5950	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DC8420	OTHER	TX	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	0097LZ	OTHER	TX	BLUE CROSS BLUE SHIELDS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427013978
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST INFECTIOUS DISEASE AND TRAVEL MEDICINE, PA

Provider Business Mailing Address
First Line	:	5509 CORNISH ST.
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-4303
Country	:	US
Telephone Number	:	832-831-5089
Fax Number	:	713-360-7715

Provider Business Practice Location Address
First Line	:	5509 CORNISH ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77007-4303
Country	:	US
Telephone Number	:	832-831-5089
Fax Number	:	713-360-7715

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PORNTHEP WATTANAMANO
Credential	:	MD
Telephone Number	:	713-384-3229

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	06/16/2021

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Directions to “NORTHWEST INFECTIOUS DISEASE AND TRAVEL MEDICINE, PA ” Practice Location

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