Provider Demographics
NPI:1194169912
Name:BELLAH, GORDON JR (MD)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:BELLAH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 SPACE PARK DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-3600
Mailing Address - Country:US
Mailing Address - Phone:281-333-1800
Mailing Address - Fax:281-335-1789
Practice Address - Street 1:2060 SPACE PARK DR
Practice Address - Street 2:SUITE 204
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-3600
Practice Address - Country:US
Practice Address - Phone:281-333-1800
Practice Address - Fax:281-335-1789
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1377174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC57681Medicare UPIN