1083141071 NPI number — PREETHI ANTONY

Table of content: PREETHI ANTONY (NPI 1083141071)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083141071 NPI number — PREETHI ANTONY

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BASIL
Provider Other First Name:
PREETHI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
AGACNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083141071
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4110 REGAL STONE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUGAR LAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77479-7118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-617-3701
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BAYLOR COLLEGE OF MEDICINE-BAYLOR ST LUKES MEDICAL GP
Provider Second Line Business Practice Location Address:
6720 BERTNER AVENUE
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-355-2666
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/22/2017

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: 363LC0200X , with the licence number:  AP133361 , 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)

  • Identifier: AP133361 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".