=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013581438
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RENE A DERAS ALVARENGA DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2021
-----------------------------------------------------
Last Update Date | 01/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2964 LEANN DR
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75033-8092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-917-4680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2802 AVENUE P
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11229-1810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-463-6648
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 692191
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------