Basic Information
| Provider Information | |||||||||
| NPI: | 1275569659 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEZERRA | ||||||||
| FirstName: | HERMINIO | ||||||||
| MiddleName: | QUIXADA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 EVANS ST | ||||||||
| Address2: | ATTN: CFO | ||||||||
| City: | UVALDE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788016051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302785604 | ||||||||
| FaxNumber: | 8302781836 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 EVANS ST | ||||||||
| Address2: | OUR HEALTH | ||||||||
| City: | UVALDE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788015142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302787105 | ||||||||
| FaxNumber: | 8302781836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 12/05/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | K4861 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | K4861 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 044914202 | 05 | TX | MEDICAID |