Provider Demographics
NPI:1003266644
Name:RUIZ, MARIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:RUIZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 HABANA ST
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78526-1897
Mailing Address - Country:US
Mailing Address - Phone:956-572-6880
Mailing Address - Fax:956-541-6183
Practice Address - Street 1:C. ALVARO OBREGON 63
Practice Address - Street 2:COL. JARDIN
Practice Address - City:MATAMOROS
Practice Address - State:TAMAULIPAS
Practice Address - Zip Code:87330
Practice Address - Country:MX
Practice Address - Phone:868-813-3022
Practice Address - Fax:868-813-6984
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ3223659122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX16963758OtherAETENA, BLUE CROSS ETC