1477828937 NPI number — ODESSA REPRODUCTIVE MEDICINE CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477828937 NPI number — ODESSA REPRODUCTIVE MEDICINE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ODESSA REPRODUCTIVE MEDICINE CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MITWALLY FERTILITY CENTER
Provider Other Organization Name Type Code:
5
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:
1477828937
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
122 CANDELARIA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HELOTES
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78023-4711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-701-4157
Provider Business Mailing Address Fax Number:
432-218-8804

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 E 6TH ST STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79761-4572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-580-4500
Provider Business Practice Location Address Fax Number:
432-218-8804
Provider Enumeration Date:
03/16/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MITWALLY
Authorized Official First Name:
MOHAMED
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
248-701-4157

Provider Taxonomy Codes

  • Taxonomy code: 207VE0102X , with the licence number:  P0765 , 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)





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