=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629225230
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALFREDO TREVINO, JR., M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2008
-----------------------------------------------------
Last Update Date | 04/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1006 E HILLSIDE RD SUITE 1
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78041-3287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-724-7179
-----------------------------------------------------
Fax | 956-725-2402
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1006 E HILLSIDE RD SUITE 1
-----------------------------------------------------
City | LAREDO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78041-3287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-724-7179
-----------------------------------------------------
Fax | 956-725-2402
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ALFREDO TREVINO JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 956-724-7179
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 6763TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | D7341
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------