Healthcare Provider Details

I. General information

NPI: 1548041767
Provider Name (Legal Business Name): SAN ISIDRO MEDICAL CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2023
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10414 MEDICAL LOOP UNIT F
LAREDO TX
78045-6612
US

IV. Provider business mailing address

10414 MEDICAL LOOP UNIT F
LAREDO TX
78045-6612
US

V. Phone/Fax

Practice location:
  • Phone: 956-462-5848
  • Fax: 956-462-5866
Mailing address:
  • Phone: 956-462-5848
  • Fax: 956-462-5866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JAZIEL SILVA-GONZALEZ
Title or Position: AUTHORIZED OFFICIAL
Credential: AUDIOLOGIST
Phone: 956-462-5848