Provider Demographics
NPI:1992879068
Name:DIAGNOSTIC & INTERNAL MEDICINE CLINIC PA
Entity type:Organization
Organization Name:DIAGNOSTIC & INTERNAL MEDICINE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:V
Authorized Official - Last Name:ZUZUKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-833-2929
Mailing Address - Street 1:2929 CALDER STREET
Mailing Address - Street 2:SUITE 308
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702
Mailing Address - Country:US
Mailing Address - Phone:409-833-2929
Mailing Address - Fax:409-839-8355
Practice Address - Street 1:2929 CALDER STREET
Practice Address - Street 2:SUITE 308
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702
Practice Address - Country:US
Practice Address - Phone:409-833-2929
Practice Address - Fax:409-839-8355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69255207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8J3606OtherBCBS
8J3606OtherBCBS
00GV11Medicare ID - Type Unspecified