Provider Demographics
NPI:1114166014
Name:CLINICA SAN MARTIN DE PORRES
Entity Type:Organization
Organization Name:CLINICA SAN MARTIN DE PORRES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ABDIAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:ETIENNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-204-6110
Mailing Address - Street 1:6101 N 23RD ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-3929
Mailing Address - Country:US
Mailing Address - Phone:956-627-2752
Mailing Address - Fax:956-627-2754
Practice Address - Street 1:6101 N 23RD ST
Practice Address - Street 2:SUITE F
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-3929
Practice Address - Country:US
Practice Address - Phone:956-627-2752
Practice Address - Fax:956-627-2754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-17
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1626261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service