Basic Information
| Provider Information | |||||||||
| NPI: | 1174584452 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASSERSTEIN | ||||||||
| FirstName: | JEROME | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WASSERSTEIN | ||||||||
| OtherFirstName: | JEROME | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4545 POST OAK PLACE DR | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770273164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7139608008 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4545 POST OAK PLACE DR | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770273164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7139608008 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 02/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | E3619 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00087AP8 | 05 | TX | MEDICAID | 133441902 | 05 | TX | MEDICAID |