Provider Demographics
NPI:1902093263
Name:LANDAVERDE, CARMEN ELENA (MD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:ELENA
Last Name:LANDAVERDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W 34TH ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1900
Mailing Address - Country:US
Mailing Address - Phone:512-454-8378
Mailing Address - Fax:512-454-8375
Practice Address - Street 1:607 CAMDEN ST STE 108
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-2100
Practice Address - Country:US
Practice Address - Phone:210-253-3426
Practice Address - Fax:210-227-6951
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5797207RG0100X, 207RI0008X, 207RT0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RT0003XAllopathic & Osteopathic PhysiciansInternal MedicineTransplant Hepatology
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX217077102Medicaid
TX217077101Medicaid
TX8CH620OtherBCBSTX
TXTXB111035Medicare PIN
TXP01111090Medicare PIN
TX217077102Medicaid