=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780865709
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLINICA MONTERREY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2007
-----------------------------------------------------
Last Update Date | 07/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5138 ASHTON AUDREY
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78249-1792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-334-3330
-----------------------------------------------------
Fax | 210-334-3334
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5138 ASHTON AUDREY
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78249-1792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-334-3330
-----------------------------------------------------
Fax | 210-334-3334
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. VICTOR MANUEL MARTINEZ-SORIA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 210-827-1014
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | K4498
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------