Provider Demographics
NPI:1386089928
Name:MOHER, JUSTIN MCDONNELL (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MCDONNELL
Last Name:MOHER
Suffix:
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 1:6621 FANNIN ST STE A210
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2399
Mailing Address - Country:US
Mailing Address - Phone:860-918-1435
Mailing Address - Fax:832-825-5426
Practice Address - Street 1:6621 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2358
Practice Address - Country:US
Practice Address - Phone:832-824-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA286880207PP0204X, 208000000X
TXR2418207PP0204X, 2080P0204X
DCMD044138208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program