1679064968 NPI number — HUMBLE DERMATOLOGY PLLC

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 1679064968 NPI number — HUMBLE DERMATOLOGY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HUMBLE DERMATOLOGY PLLC
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:
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:
1679064968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18980 NORTH MEMORIAL DRIVE
Provider Second Line Business Mailing Address:
STE. 200
Provider Business Mailing Address City Name:
HUMBLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-707-6400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18980 NORTH MEMORIAL DRIVE
Provider Second Line Business Practice Location Address:
STE. 200
Provider Business Practice Location Address City Name:
HUMBLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-707-6400
Provider Business Practice Location Address Fax Number:
281-584-6432
Provider Enumeration Date:
05/23/2018

Additional Information

Authorized Official

Authorized Official Last Name:
EGESI
Authorized Official First Name:
PRINCE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
281-707-6400

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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