Basic Information
| Provider Information | |||||||||
| NPI: | 1629136130 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OBALLO | ||||||||
| FirstName: | FELINO | ||||||||
| MiddleName: | CANENDO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9901 VALDERRAMA DR | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787173847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306727581 | ||||||||
| FaxNumber: | 8306728481 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 N SARAH DEWITT DR | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786293311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306727581 | ||||||||
| FaxNumber: | 8306722401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 12/10/2014 | ||||||||
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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 | 208600000X | F8596 | TX | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00MC06 | 01 | TX | MC | OTHER | 8L5471 | 01 | TX | MC PTAN | OTHER | 114639101 | 05 | TX | MEDICAID |