Provider Demographics
NPI:1073508222
Name:LLANES, CARLOS MAURICIO (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:MAURICIO
Last Name:LLANES
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:PO BOX 2926
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78044-2926
Mailing Address - Country:US
Mailing Address - Phone:956-795-4770
Mailing Address - Fax:956-795-4773
Practice Address - Street 1:1519 E BUSTAMANTE ST
Practice Address - Street 2:SUITE E
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-5305
Practice Address - Country:US
Practice Address - Phone:956-795-4770
Practice Address - Fax:956-795-4773
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4019207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139535218Medicaid
TXF42317Medicare UPIN
TX139535218Medicaid
TX8899B0Medicare PIN