Provider Demographics
NPI:1073791026
Name:ROBERT C BRACE
Entity Type:Organization
Organization Name:ROBERT C BRACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GONGORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-682-4187
Mailing Address - Street 1:533 PECAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-2356
Mailing Address - Country:US
Mailing Address - Phone:956-682-4187
Mailing Address - Fax:956-682-9739
Practice Address - Street 1:533 PECAN BLVD
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-2356
Practice Address - Country:US
Practice Address - Phone:956-682-4187
Practice Address - Fax:956-682-9739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0548213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160138702OtherMEDICAID DME
TX127193403Medicaid
TX0916420001Medicare NSC
TX127193403Medicaid
TX00CE42Medicare PIN