Basic Information
| Provider Information | |||||||||
| NPI: | 1538658422 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEN AND WOMENS VITALITY CENTER PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 799 | ||||||||
| Address2: | |||||||||
| City: | FRIENDSWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775490799 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 308 S FRIENDSWOOD DR STE 110 | ||||||||
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| City: | FRIENDSWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775463989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819933733 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2018 | ||||||||
| LastUpdateDate: | 05/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | QAYYUM | ||||||||
| AuthorizedOfficialFirstName: | MOHSIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6303278029 | ||||||||
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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 | 207V00000X | N2195 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 214325703 | 05 | TX | MEDICAID |