Provider Demographics
NPI:1528205150
Name:ORVILLE D CERNA MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:ORVILLE D CERNA MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ORVILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CERENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-447-2030
Mailing Address - Street 1:925 W DAGGETT ST
Mailing Address - Street 2:
Mailing Address - City:PECOS
Mailing Address - State:TX
Mailing Address - Zip Code:79772-6902
Mailing Address - Country:US
Mailing Address - Phone:432-447-2030
Mailing Address - Fax:432-447-7347
Practice Address - Street 1:925 W DAGGETT ST
Practice Address - Street 2:
Practice Address - City:PECOS
Practice Address - State:TX
Practice Address - Zip Code:79772-6902
Practice Address - Country:US
Practice Address - Phone:432-447-2030
Practice Address - Fax:432-447-7347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1207207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123260503Medicaid
A29325Medicare UPIN
TX123260503Medicaid