1104040641 NPI number — NORTH HOUSTON DIAGNOSTIC CTR PA

Table of content: MICHAEL BENJAMIN DWYER LMSW (NPI 1477012342)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104040641 NPI number — NORTH HOUSTON DIAGNOSTIC CTR PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH HOUSTON DIAGNOSTIC CTR PA
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:
6
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:
1104040641
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11940
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:
77293-1940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-694-0357
Provider Business Mailing Address Fax Number:
713-699-6218

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5990 AIRLINE DR
Provider Second Line Business Practice Location Address:
#290
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77076-4233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-694-0357
Provider Business Practice Location Address Fax Number:
713-699-6218
Provider Enumeration Date:
04/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHAH
Authorized Official First Name:
KOKI
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
713-699-6202

Provider Taxonomy Codes

  • Taxonomy code: 2081H0002X , with the licence number:  G1258 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 8130 , 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: MDG1258 . This is a "DR CHANA WC AND COMM" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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