Healthcare Provider Details

I. General information

NPI: 1801825740
Provider Name (Legal Business Name): MARIO PEREZ DO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8555 N STATE HIGHWAY 16
POTEET TX
78065-4034
US

IV. Provider business mailing address

8555 N STATE HIGHWAY 16
POTEET TX
78065-4034
US

V. Phone/Fax

Practice location:
  • Phone: 830-742-3637
  • Fax: 830-742-3534
Mailing address:
  • Phone: 830-742-3637
  • Fax: 830-742-3534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberK4526
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MARIO PEREZ
Title or Position: PHYSICIAN OWNER
Credential: D.O.
Phone: 830-742-3637