Basic Information
| Provider Information | |||||||||
| NPI: | 1407163116 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRAZOSPORT WOMENS HEALTH PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 OAK DRIVE SOUTH | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LAKE JACKSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775665617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9792669544 | ||||||||
| FaxNumber: | 9795299737 | ||||||||
| Practice Location | |||||||||
| Address1: | 506 THIS WAY ST | ||||||||
| Address2: | |||||||||
| City: | LAKE JACKSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775665128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9792669544 | ||||||||
| FaxNumber: | 9795299737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2010 | ||||||||
| LastUpdateDate: | 06/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | KADIYALA | ||||||||
| AuthorizedOfficialFirstName: | SAMATHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN - OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9792669544 | ||||||||
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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 | 207VG0400X | N4502 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
No ID Information.