Healthcare Provider Details

I. General information

NPI: 1861498966
Provider Name (Legal Business Name): CARLOS P DE JUANA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 02/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E SAVANNAH AVE BLDG C101
MCALLEN TX
78503-1242
US

IV. Provider business mailing address

110 E SAVANNAH AVE BLDG C101
MCALLEN TX
78503-1242
US

V. Phone/Fax

Practice location:
  • Phone: 956-686-8357
  • Fax: 956-686-5030
Mailing address:
  • Phone: 956-686-8357
  • Fax: 956-686-5030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberE3679
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: