Provider Demographics
NPI:1477675163
Name:LAREDO SPORTS MEDICINE CLINIC, PA
Entity Type:Organization
Organization Name:LAREDO SPORTS MEDICINE CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:V
Authorized Official - Last Name:PUIG
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:956-727-2122
Mailing Address - Street 1:7109 N BARTLETT AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-6473
Mailing Address - Country:US
Mailing Address - Phone:956-727-2122
Mailing Address - Fax:956-727-4445
Practice Address - Street 1:7109 N BARTLETT AVE STE 109
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6473
Practice Address - Country:US
Practice Address - Phone:956-727-2122
Practice Address - Fax:956-727-4445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0045KNOtherBCBS
TX1591232-02Medicaid
TX5326520001Medicare NSC
TX0045KNOtherBCBS