Provider Demographics
NPI:1346221116
Name:IGLESIAS, JOSE L (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:L
Last Name:IGLESIAS
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-6163
Mailing Address - Fax:682-885-7347
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-7080
Practice Address - Fax:682-885-7085
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ42312086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142711407OtherCSHCN
TX150220508OtherMEDICAID GROUP NUMBER
TX7286138OtherAETNA
TX0134405OtherUNITED HEALTH PLAN
TX125744OtherSUPERIOR CHIP
TX150220509OtherCSHCN GROUP NUMBER
TX00U87ZOtherMEDICARE GROUP NUMBER
TX142711405OtherCSHCN
TX137345810OtherCSHCN GROUP NUMBER
TX140442852OtherMEDICAID GROUP NUMBER
TX41840OtherAETNA MEDICAID
TX142711403OtherCSCHS
TX142711406Medicaid
TX80391NOtherBLUE CROSS
TX9151575OtherPHCS
TX142711401Medicaid
TX100360788OtherAMERIGROUP
TX00257TOtherMEDICARE GROUP NUMBER
TX142711404Medicaid
TX5173257002OtherCIGNA
TX153410012OtherPACIFICARE
TX100360788OtherAMERIGROUP
TX142711404Medicaid
TX8L19378Medicare PIN
TX80391NMedicare PIN