Healthcare Provider Details

I. General information

NPI: 1124080361
Provider Name (Legal Business Name): MIGUEL A CAVAZOS JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 LOGAN
LAREDO TX
78040
US

IV. Provider business mailing address

1616 LOGAN
LAREDO TX
78040
US

V. Phone/Fax

Practice location:
  • Phone: 956-722-5162
  • Fax: 956-722-0676
Mailing address:
  • Phone: 956-722-5162
  • Fax: 956-722-0676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD5267
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: