Provider Demographics
NPI:1033370176
Name:TREVINO, EDGAR ALBERTO (MD)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:ALBERTO
Last Name:TREVINO
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 1:101 W VILLAGE BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-2211
Mailing Address - Country:US
Mailing Address - Phone:956-285-7785
Mailing Address - Fax:956-994-9082
Practice Address - Street 1:101 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239
Practice Address - Country:US
Practice Address - Phone:360-678-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4805207Q00000X
MT61897208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB100623OtherMEDICARE GRP NUMBER
TX1669794657OtherNPI GROUP NUMBER
TX212222801Medicaid
TX212220201OtherMEDICAID GROUP NUMBER
TX212220202OtherMEDICAID TEXAS HEALTH STEPS
TX212222801Medicaid