MEDICARE: WEST HOUSTON FAMILY PRACTICE

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	174400000X	Specialist	L1561	TX

General Provider Information

NPI Number	:	1972957280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST HOUSTON FAMILY PRACTICE

Provider Business Mailing Address
First Line	:	12245 RICHMOND AVE
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77082-2518
Country	:	US
Telephone Number	:	281-558-6700
Fax Number	:	281-558-1741

Provider Business Practice Location Address
First Line	:	12245 RICHMOND AVE
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77082-2518
Country	:	US
Telephone Number	:	281-558-6700
Fax Number	:	281-558-1741

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	MR. TIMOTHY J DETTER
Credential	:	M.D.
Telephone Number	:	281-558-6700

Provider Enumeration Date	:	04/22/2016
Last Update Date	:	04/22/2016

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Directions to “WEST HOUSTON FAMILY PRACTICE ” Practice Location

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