Provider Demographics
NPI:1366517088
Name:FEDERICO VALDERRAMA-BAZAN, M.D.,P.A.
Entity type:Organization
Organization Name:FEDERICO VALDERRAMA-BAZAN, M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FEDERICO
Authorized Official - Middle Name:
Authorized Official - Last Name:VALDERRAMA-BAZAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-839-4757
Mailing Address - Street 1:810 HOSPITAL DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-4600
Mailing Address - Country:US
Mailing Address - Phone:409-839-4757
Mailing Address - Fax:409-839-4294
Practice Address - Street 1:810 HOSPITAL DR
Practice Address - Street 2:SUITE 320
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-4600
Practice Address - Country:US
Practice Address - Phone:409-839-4757
Practice Address - Fax:409-839-4294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE3488207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123414807Medicaid
TX172224101Medicaid
TX172224101Medicaid
TX00876XMedicare PIN