Basic Information
| Provider Information | |||||||||
| NPI: | 1962697649 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | M M ONTIVEROS MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 CAMDEN ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782152012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102819800 | ||||||||
| FaxNumber: | 2102811001 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 CAMDEN ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782152012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102819800 | ||||||||
| FaxNumber: | 2102811001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2007 | ||||||||
| LastUpdateDate: | 05/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | MATHIS | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2105251668 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | H5196 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 149380101 | 05 | TX | MEDICAID |