Basic Information
Provider Information | |||||||||
NPI: | 1932198397 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEIKERT | ||||||||
FirstName: | MITCHELL | ||||||||
MiddleName: | P. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6550 FANNIN ST | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770302717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7137986100 | ||||||||
FaxNumber: | 7137984231 | ||||||||
Practice Location | |||||||||
Address1: | 1977 BUTLER BLVD | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770304101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7137986100 | ||||||||
FaxNumber: | 7137984231 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/18/2005 | ||||||||
LastUpdateDate: | 12/04/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/04/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | L6713 | TX | Y |   | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | 159813802 | 05 | TX |   | MEDICAID | 4259873 | 01 | TX | BLUE LINK | OTHER | 159813801 | 05 | TX |   | MEDICAID | 8J3913 | 01 | TX | BC/BS | OTHER |