Provider Demographics
NPI:1902987811
Name:STASICHA, THOMAS R JR (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:STASICHA
Suffix:JR
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 1:6363 SAN FELIPE ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-2708
Mailing Address - Country:US
Mailing Address - Phone:713-972-8900
Mailing Address - Fax:888-876-4946
Practice Address - Street 1:6363 SAN FELIPE ST
Practice Address - Street 2:SUITE 150
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-2708
Practice Address - Country:US
Practice Address - Phone:713-972-8900
Practice Address - Fax:888-876-4946
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4957207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX186591701Medicaid
TX186591702Medicaid
TX8J5071Medicare PIN
TX8J5074Medicare PIN
TX8J5073Medicare PIN
TX8J5072Medicare PIN