Provider Demographics
NPI:1558386763
Name:MIJARES, CARLOS J (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:J
Last Name:MIJARES
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 1:3455 LOCKE AVE STE 315
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-5745
Mailing Address - Country:US
Mailing Address - Phone:817-336-1189
Mailing Address - Fax:817-877-5665
Practice Address - Street 1:3455 LOCKE AVE STE 315
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107
Practice Address - Country:US
Practice Address - Phone:817-336-1189
Practice Address - Fax:817-877-5665
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5929207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX073430303Medicaid
TX073430302Medicaid
TXC97978Medicare UPIN
TX073430302Medicaid
TX8A6500Medicare ID - Type Unspecified