Provider Demographics
NPI:1235328113
Name:TREVINO, JOSE GUILLERMO (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:GUILLERMO
Last Name:TREVINO
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 1:3141 IRVING BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-6232
Mailing Address - Country:US
Mailing Address - Phone:214-630-1144
Mailing Address - Fax:214-631-6815
Practice Address - Street 1:3141 IRVING BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-6232
Practice Address - Country:US
Practice Address - Phone:214-630-1144
Practice Address - Fax:214-631-6815
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8873174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE64938Medicare UPIN