Provider Demographics
NPI:1427030196
Name:IGLESIAS, JOSE VICTOR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:VICTOR
Last Name:IGLESIAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MRS
Other - First Name:SARA
Other - Middle Name:DIB
Other - Last Name:IGLESIAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CMOM
Mailing Address - Street 1:17203 RED OAK DR STE 202
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-2613
Mailing Address - Country:US
Mailing Address - Phone:281-444-9400
Mailing Address - Fax:281-444-1224
Practice Address - Street 1:17203 RED OAK DR STE 202
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2613
Practice Address - Country:US
Practice Address - Phone:281-444-9400
Practice Address - Fax:281-444-1254
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1343174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX099690201Medicaid
TX8F23641Medicare PIN
TX099690201Medicaid