Organization
BRAZOSPORT UROLOGY, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DERRICK ANTHONY BERGER (PRACTICE MANAGER)
(979) 297-4140
Entity
Organization
Contact information
Practice address
115 ABNER JACKSON PKWY, SUITE C, LAKE JACKSON, TX 77566-5157
(979) 297-4140
(979) 297-4919
Mailing address
115 ABNER JACKSON PKWY, SUITE C, LAKE JACKSON, TX 77566-5157
(979) 297-4140
(979) 297-4919
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
M5052
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
192358301
—
TX
Enumeration date
04/26/2007
Last updated
06/23/2008
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