Provider Demographics
NPI:1386916989
Name:SPRING CREEK UROLOGY SPECIALISTS LLC
Entity type:Organization
Organization Name:SPRING CREEK UROLOGY SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KWATRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-259-2872
Mailing Address - Street 1:PO BOX 4346
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4346
Mailing Address - Country:US
Mailing Address - Phone:855-259-2872
Mailing Address - Fax:888-815-6161
Practice Address - Street 1:506 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2942
Practice Address - Country:US
Practice Address - Phone:855-259-2872
Practice Address - Fax:888-815-6161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-30
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6530208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX303906701Medicaid
TXTXB149578Medicare PIN