Healthcare Provider Details

I. General information

NPI: 1841456852
Provider Name (Legal Business Name): CHILDREN'S CLINIC OF DIMMIT AND ZAVALA, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 VETERANS AVENUE SUITE C
CRYSTAL CITY TX
78839-2828
US

IV. Provider business mailing address

403 S 7TH ST
CARRIZO SPRINGS TX
78834-3805
US

V. Phone/Fax

Practice location:
  • Phone: 830-374-4436
  • Fax: 830-374-4437
Mailing address:
  • Phone: 830-876-9870
  • Fax: 830-876-3661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberK0721
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ABELARDO SABANGAN DORIA
Title or Position: PRESIDENT
Credential: MD
Phone: 830-876-9870