Basic Information
| Provider Information | |||||||||
| NPI: | 1659799518 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JD UNITED, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3917 PEBBLE BROOK DR | ||||||||
| Address2: | |||||||||
| City: | LEAGUE CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775733766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8325245355 | ||||||||
| FaxNumber: | 2819917700 | ||||||||
| Practice Location | |||||||||
| Address1: | 5010 CRENSHAW RD | ||||||||
| Address2: | SUITE #130 | ||||||||
| City: | PASADENA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775053097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819912200 | ||||||||
| FaxNumber: | 2819917700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2014 | ||||||||
| LastUpdateDate: | 03/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | FUKE | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2819912200 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 208VP0014X | M6138 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6987950001 | 01 | TX | PTAN | OTHER |