1417447798 NPI number — DR. IRVIN JUSTIN QUEZON MD

Table of content: MRS. JESSICA I FUSSELL MCD (NPI 1407064520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417447798 NPI number — DR. IRVIN JUSTIN QUEZON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUEZON
Provider First Name:
IRVIN
Provider Middle Name:
JUSTIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1417447798
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2900 N BRAESWOOD BLVD APT 3123
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:
77025-2360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-349-3574
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18839 MCKAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77338-5721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-446-3655
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/13/2018

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: 208600000X , with the licence number:  R77019 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: T8919 , 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)