Basic Information
| Provider Information | |||||||||
| NPI: | 1174936348 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DTL MEDICAL MANAGEMENT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2820 S COTSWOLD MANOR DR | ||||||||
| Address2: | |||||||||
| City: | KINGWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815931500 | ||||||||
| FaxNumber: | 2815931506 | ||||||||
| Practice Location | |||||||||
| Address1: | 2820 S COTSWOLD MANOR DR | ||||||||
| Address2: | |||||||||
| City: | KINGWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815931500 | ||||||||
| FaxNumber: | 2815931506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2014 | ||||||||
| LastUpdateDate: | 06/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | LE | ||||||||
| AuthorizedOfficialFirstName: | DUC | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2815931500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M8117 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.