Provider Demographics
NPI:1154623072
Name:RUKSHAN AZHAR MDPA
Entity type:Organization
Organization Name:RUKSHAN AZHAR MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUKSHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AZHAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-428-7997
Mailing Address - Street 1:2802 GARTH RD STE 105
Mailing Address - Street 2:
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77521-3924
Mailing Address - Country:US
Mailing Address - Phone:713-885-5070
Mailing Address - Fax:
Practice Address - Street 1:855 ROLLINGBROOK DR STE 105
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521-4073
Practice Address - Country:US
Practice Address - Phone:713-885-5070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ78942084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113400902Medicaid
TX113400902Medicaid
TX0027AYMedicare PIN