Provider Demographics
NPI:1528003936
Name:ANZALDUA, MARIO RUDY (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:RUDY
Last Name:ANZALDUA
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 1:1512 E GRIFFIN PKWY STE 2
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-2422
Mailing Address - Country:US
Mailing Address - Phone:956-519-7088
Mailing Address - Fax:956-519-9816
Practice Address - Street 1:1512 E GRIFFIN PKWY STE 2
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-2422
Practice Address - Country:US
Practice Address - Phone:956-519-7088
Practice Address - Fax:956-519-9816
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9142207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127155304OtherTHSTEPS MEDICAID
TX176830600OtherUS DEPARTMENT OF LABOR / W/C
TX127155301Medicaid
TX127155301Medicaid
TX00FR35Medicare ID - Type Unspecified