Provider Demographics
NPI:1114024478
Name:LETICIA A PORET MD PA
Entity Type:Organization
Organization Name:LETICIA A PORET MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PORET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-733-3005
Mailing Address - Street 1:12627 STONEHENGE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-1941
Mailing Address - Country:US
Mailing Address - Phone:210-733-3005
Mailing Address - Fax:
Practice Address - Street 1:4522 FREDERICKSBURG RD
Practice Address - Street 2:SUITE A 14
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78201-6521
Practice Address - Country:US
Practice Address - Phone:210-733-3005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9289207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0009QFOtherBC BS
TX00182UOtherMEDICARE