Basic Information
| Provider Information | |||||||||
| NPI: | 1104806629 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONDON | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1415 NORTH LOOP W STE 240 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770081677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134264010 | ||||||||
| FaxNumber: | 7134264015 | ||||||||
| Practice Location | |||||||||
| Address1: | 7401 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770304509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136217436 | ||||||||
| FaxNumber: | 7137998600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G5309 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 124654805 | 05 | TX | MEDICAID |