Provider Demographics
NPI:1902061575
Name:OUTREACH DIAGNOSTIC CLINIC
Entity Type:Organization
Organization Name:OUTREACH DIAGNOSTIC CLINIC
Other - Org Name:WILLS DIAGNOSTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KIGGUNDU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-532-7311
Mailing Address - Street 1:5120 WOODWAY DRIVE
Mailing Address - Street 2:SUITE 7012
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77056-1791
Mailing Address - Country:US
Mailing Address - Phone:713-532-7311
Mailing Address - Fax:
Practice Address - Street 1:2000 CRAWFORD ST
Practice Address - Street 2:SUITE 900
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77002-9011
Practice Address - Country:US
Practice Address - Phone:713-651-0870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0083207R00000X
TXM3453207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197746401Medicaid
TX197746401Medicaid