Basic Information
| Provider Information | |||||||||
| NPI: | 1700012143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELJOUI | ||||||||
| FirstName: | KATY | ||||||||
| MiddleName: | MELODY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DELJOUI | ||||||||
| OtherFirstName: | KATAYOUN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6565 FANNIN ST | ||||||||
| Address2: | SUITE 1003 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134411100 | ||||||||
| FaxNumber: | 7137906334 | ||||||||
| Practice Location | |||||||||
| Address1: | 6565 FANNIN ST | ||||||||
| Address2: | SUITE 1003 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134411100 | ||||||||
| FaxNumber: | 7137906334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2009 | ||||||||
| LastUpdateDate: | 09/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Q0242 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207RC0200X | Q0242 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 341816203 | 05 | TX | MEDICAID | 8FD219 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |