Healthcare Provider Details

I. General information

NPI: 1417175209
Provider Name (Legal Business Name): PEDRO JUAN LOREDO III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 E STATE HIGHWAY 114 STE 380
SOUTHLAKE TX
76092-4414
US

IV. Provider business mailing address

431 E STATE HIGHWAY 114 STE 380
SOUTHLAKE TX
76092-4414
US

V. Phone/Fax

Practice location:
  • Phone: 972-939-4974
  • Fax: 817-280-9870
Mailing address:
  • Phone: 972-939-4974
  • Fax: 817-280-9870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301080172
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License NumberN0228
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number40806
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number40806
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberN0228
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: