Basic Information
| Provider Information | |||||||||
| NPI: | 1487096764 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NINAN | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | TARA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. MBBS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11511 SHADOW CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | PEARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775847298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134420000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2727 W HOLCOMBE BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770251669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134420000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2013 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | S4033 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100011142 | 01 | CA | MEDICAL LICENCE NUMBER | OTHER | 408640702 | 05 | TX | MEDICAID | 408640703 | 05 | TX | MEDICAID | 408640701 | 05 | TX | MEDICAID |