Healthcare Provider Details

I. General information

NPI: 1619091295
Provider Name (Legal Business Name): RICARDO DE LOS SANTOS, M.D.,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2198 E. GARRISON ST. STE. 1
EAGLE PASS TX
78852-5076
US

IV. Provider business mailing address

2198 E. GARRISON ST. STE. 1
EAGLE PASS TX
78852-5076
US

V. Phone/Fax

Practice location:
  • Phone: 830-773-1103
  • Fax: 830-757-8366
Mailing address:
  • Phone: 830-773-1103
  • Fax: 830-757-8366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number45D0506351
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberF3442
License Number StateTX

VIII. Authorized Official

Name: MRS. DEBRA W. DE LOS SANTOS
Title or Position: CEO
Credential:
Phone: 830-773-1103