Provider Demographics
NPI:1437192085
Name:MALDONADO, JORGE LUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:LUIS
Last Name:MALDONADO
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 1:1634 LOCKHILL SELMA RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1929
Mailing Address - Country:US
Mailing Address - Phone:210-541-8455
Mailing Address - Fax:
Practice Address - Street 1:1634 LOCKHILL SELMA RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-1929
Practice Address - Country:US
Practice Address - Phone:210-541-8455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2359174400000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149418903Medicaid
TX00981FMedicare PIN
TXG63935Medicare UPIN