Provider Demographics
NPI:1164491619
Name:COIMBRA, CAETANO JOSE PORTO (MD)
Entity Type:Individual
Prefix:
First Name:CAETANO
Middle Name:JOSE PORTO
Last Name:COIMBRA
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 1:7777 FOREST LN STE A337
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2563
Mailing Address - Country:US
Mailing Address - Phone:972-566-5200
Mailing Address - Fax:972-566-5100
Practice Address - Street 1:7777 FOREST LN STE A337
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2563
Practice Address - Country:US
Practice Address - Phone:972-566-5200
Practice Address - Fax:972-566-5100
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6909207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F98076Medicare UPIN