Basic Information
| Provider Information | |||||||||
| NPI: | 1194098129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CERVANTEZ | ||||||||
| FirstName: | FEDERICO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CERVANTEZ | ||||||||
| OtherFirstName: | FREDDY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 902 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | CARRIZO SPRINGS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788344206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 902 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | CARRIZO SPRINGS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788344206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8308762611 | ||||||||
| FaxNumber: | 8308763776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2012 | ||||||||
| LastUpdateDate: | 02/24/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | CONTROL #10813 | TX | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.