Provider Demographics
NPI:1144478694
Name:SOUTH TEXAS FOOT & ANKLE SPECIALIST PA
Entity type:Organization
Organization Name:SOUTH TEXAS FOOT & ANKLE SPECIALIST PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PABLO
Authorized Official - Middle Name:
Authorized Official - Last Name:TREVINO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:956-718-0075
Mailing Address - Street 1:6419 POLARIS
Mailing Address - Street 2:SUITE A 1
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-4725
Mailing Address - Country:US
Mailing Address - Phone:956-718-0075
Mailing Address - Fax:956-718-0086
Practice Address - Street 1:6419 POLARIS
Practice Address - Street 2:SUITE A 1
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-4725
Practice Address - Country:US
Practice Address - Phone:956-718-0075
Practice Address - Fax:956-718-0086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1856213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1407041809OtherINDIVIDUAL NPI
TX6189200001Medicare NSC
TX00Z787Medicare PIN