Provider Demographics
NPI:1114960663
Name:AYALA, JOSE MARIO (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MARIO
Last Name:AYALA
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 1:1301 WONDER WORLD DR
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7533
Mailing Address - Country:US
Mailing Address - Phone:512-353-8979
Mailing Address - Fax:
Practice Address - Street 1:1301 WONDER WORLD DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7533
Practice Address - Country:US
Practice Address - Phone:512-353-8979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5037207R00000X
IL036104962207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8X6220OtherBCBS PROVIDER#
IL036104962Medicaid
TX8X6220OtherBCBS PROVIDER#
IL036104962Medicaid
TX351333YM8AMedicare PIN
TX8J2090Medicare PIN