Provider Demographics
NPI:1619027133
Name:HERMOSO, MARCOS ROSAURO JR (MD)
Entity type:Individual
Prefix:
First Name:MARCOS
Middle Name:ROSAURO
Last Name:HERMOSO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4832
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:2411 FOUNTAIN VIEW DR
Practice Address - Street 2:SUITE 200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-4817
Practice Address - Country:US
Practice Address - Phone:713-458-4185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0821207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81316KOtherIN HARRIS - MEDICARE
TX122183002Medicaid
TX8016J2OtherOUT HARRIS - MEDICARE
81316KOtherTX-BLUE SHIELD
TX050056901OtherRAILROAD - MEDICARE
LA1375012OtherLA - MEDICAID