Basic Information
| Provider Information | |||||||||
| NPI: | 1316000144 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPARTMENT OF STATE HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TEXAS CENTER FOR INFECTIOUS DISEASE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4110 GUADALUPE ST | ||||||||
| Address2: | HOSPITAL REVENUE MGMT-MC2028 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787514223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122065011 | ||||||||
| FaxNumber: | 5122065302 | ||||||||
| Practice Location | |||||||||
| Address1: | 2303 SE MILITARY DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782233542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105317809 | ||||||||
| FaxNumber: | 2105317796 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 08/09/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BALTIERRA | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | TEAM LEAD | ||||||||
| AuthorizedOfficialTelephone: | 5122065011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | TX | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1332579-04 | 05 | TX | MEDICAID | HH4568 | 01 | TX | BCBS | OTHER |