Provider Demographics
NPI:1477583367
Name:BELASCO, MARVIN SAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:SAM
Last Name:BELASCO
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 1:207 E MANDALAY DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-1741
Mailing Address - Country:US
Mailing Address - Phone:210-223-5443
Mailing Address - Fax:210-225-1171
Practice Address - Street 1:1303 MCCULLOUGH AVE
Practice Address - Street 2:125
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-5609
Practice Address - Country:US
Practice Address - Phone:210-223-5443
Practice Address - Fax:210-225-1171
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8317174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE03323Medicare UPIN
TX83R363Medicare PIN