1346459542 NPI number — DR. SOWDHAMINI SHETTIGAR WALLACE D.O.

Table of content: DR. SOWDHAMINI SHETTIGAR WALLACE D.O. (NPI 1346459542)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346459542 NPI number — DR. SOWDHAMINI SHETTIGAR WALLACE D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
SOWDHAMINI
Provider Middle Name:
SHETTIGAR
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHETTIGAR
Provider Other First Name:
SOWDHAMINI
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346459542
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9113 HARBOR HILLS DR
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:
77054-6009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-554-4093
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6621 FANNIN ST STE A210
Provider Second Line Business Practice Location Address:
TEXAS CHILDREN'S HOSPITAL, PEDIATRIC HOSPITAL MEDICINE
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77030-2303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-839-0492
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/22/2007

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: 208000000X , with the licence number:  N0540 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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