Provider Demographics
NPI:1477698942
Name:MEDICAL TRAUMA SPECIALIST
Entity Type:Organization
Organization Name:MEDICAL TRAUMA SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-668-9800
Mailing Address - Street 1:PO BOX 4582
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78502-4582
Mailing Address - Country:US
Mailing Address - Phone:956-668-9800
Mailing Address - Fax:956-668-8438
Practice Address - Street 1:1708 N CAGE BLVD
Practice Address - Street 2:
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577-2528
Practice Address - Country:US
Practice Address - Phone:956-668-9800
Practice Address - Fax:956-668-8438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3002213416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000708001Medicaid
TXAMB047Medicare PIN