Basic Information
| Provider Information | |||||||||
| NPI: | 1497168546 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHAUN S. VARGHESE, M.D., PLLC | ||||||||
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| OtherOrganizationName: | THE HOUSTON INSTITUTE OF NEUROLOGY FOR KIDS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 MEDICAL PLAZA DR | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | SHENANDOAH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773803260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812981144 | ||||||||
| FaxNumber: | 2812981133 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 MEDICAL PLAZA DR | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | SHENANDOAH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773803260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812981144 | ||||||||
| FaxNumber: | 2812981133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2014 | ||||||||
| LastUpdateDate: | 09/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | VARGHESE | ||||||||
| AuthorizedOfficialFirstName: | SHAUN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8327678365 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0008X | P9760 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities | 2084N0402X | P9760 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | 339121101 | 05 | TX | MEDICAID |