Provider Demographics
NPI:1417175209
Name:LOREDO, PEDRO JUAN III (MD)
Entity Type:Individual
Prefix:DR
First Name:PEDRO
Middle Name:JUAN
Last Name:LOREDO
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:220 N PARK BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-6900
Mailing Address - Country:US
Mailing Address - Phone:972-939-4974
Mailing Address - Fax:817-280-9870
Practice Address - Street 1:220 N PARK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-6900
Practice Address - Country:US
Practice Address - Phone:972-939-4974
Practice Address - Fax:817-280-9870
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40806207P00000X, 2086S0105X
TXN0228207XS0106X, 2086S0105X
MI4301080172208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX378258Medicare UPIN