Healthcare Provider Details

I. General information

NPI: 1740445758
Provider Name (Legal Business Name): MARIO RIZALINO BASCON ROA JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2008
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4421 HIGHWAY 6 S STE 100
COLLEGE STATION TX
77845-6176
US

IV. Provider business mailing address

1530 TEXAS AVE S STE 100
COLLEGE STATION TX
77840-3329
US

V. Phone/Fax

Practice location:
  • Phone: 979-731-5200
  • Fax: 979-731-5210
Mailing address:
  • Phone: 979-690-4878
  • Fax: 979-690-4879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberN7865
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: