1073774766 NPI number — JODI WELLNER RD

Table of content: JODI WELLNER RD (NPI 1073774766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073774766 NPI number — JODI WELLNER RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WELLNER
Provider First Name:
JODI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073774766
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 66308
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77266-6308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-830-3060
Provider Business Mailing Address Fax Number:
713-523-4897

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3311 RICHMOND AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-830-3033
Provider Business Practice Location Address Fax Number:
713-523-4897
Provider Enumeration Date:
06/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  DT07555 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 133V00000X , with the licence number: 952398 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 184297301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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