Provider Demographics
NPI:1124043344
Name:TEIXEIRA, PAUL A (PT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:TEIXEIRA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1248 MONTEREY ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3104
Mailing Address - Country:US
Mailing Address - Phone:805-541-8005
Mailing Address - Fax:805-541-8010
Practice Address - Street 1:1248 MONTEREY ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3104
Practice Address - Country:US
Practice Address - Phone:805-541-8005
Practice Address - Fax:805-541-8010
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT18625174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT18625Medicare PIN