Basic Information
| Provider Information | |||||||||
| NPI: | 1013525880 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVANCED GASTROENTEROLOGY AND NUTRITION OF TEXAS PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 27211 ASHFORD SKY LN | ||||||||
| Address2: | |||||||||
| City: | KATY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774943715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145061136 | ||||||||
| FaxNumber: | 2147053786 | ||||||||
| Practice Location | |||||||||
| Address1: | 2255 E MOSSY OAKS RD STE 500 | ||||||||
| Address2: | |||||||||
| City: | SPRING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773891813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145061136 | ||||||||
| FaxNumber: | 2147053786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2020 | ||||||||
| LastUpdateDate: | 07/17/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AHMED | ||||||||
| AuthorizedOfficialFirstName: | AMIR | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8326226621 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.