Provider Demographics
NPI:1033509732
Name:DIABETES AND CARDIOVASCULAR OF ROCKPORT, PLLC
Entity Type:Organization
Organization Name:DIABETES AND CARDIOVASCULAR OF ROCKPORT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:361-790-5155
Mailing Address - Street 1:2600 LAKEVIEW DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:ROCKPORT
Mailing Address - State:TX
Mailing Address - Zip Code:78382-3552
Mailing Address - Country:US
Mailing Address - Phone:361-790-5155
Mailing Address - Fax:361-790-5156
Practice Address - Street 1:2600 LAKEVIEW DR
Practice Address - Street 2:SUITE D
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-3552
Practice Address - Country:US
Practice Address - Phone:361-790-5155
Practice Address - Fax:361-790-5156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4526207Q00000X
TXJ1539208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00N7N0OtherBCBS
TX401524Medicare UPIN