Provider Demographics
NPI:1508146622
Name:MARIO A. QUINTANILLA MD, PLLC
Entity Type:Organization
Organization Name:MARIO A. QUINTANILLA MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:QUINTANILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-993-4793
Mailing Address - Street 1:5866 S STAPLES ST
Mailing Address - Street 2:SUITE #401
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-3700
Mailing Address - Country:US
Mailing Address - Phone:361-993-4793
Mailing Address - Fax:361-993-1118
Practice Address - Street 1:5866 S STAPLES ST
Practice Address - Street 2:SUITE #401
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-3700
Practice Address - Country:US
Practice Address - Phone:361-993-4793
Practice Address - Fax:361-993-1118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-20
Last Update Date:2011-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1201103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139788713Medicaid
TX139788713Medicaid