Provider Demographics
NPI:1578763462
Name:PORET, LETICIA A (MD PA)
Entity Type:Individual
Prefix:DR
First Name:LETICIA
Middle Name:A
Last Name:PORET
Suffix:
Gender:F
Credentials:MD PA
Other - Prefix:DR
Other - First Name:LETICIA
Other - Middle Name:A
Other - Last Name:PORET
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD PA
Mailing Address - Street 1:12627 STONEHENGE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-1941
Mailing Address - Country:US
Mailing Address - Phone:210-733-3005
Mailing Address - Fax:210-733-3005
Practice Address - Street 1:4522 FREDERICKSBURG RD STE A14
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78201-6595
Practice Address - Country:US
Practice Address - Phone:210-733-3005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9289207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AJ423OtherBC BS
TX157488101Medicaid
TX8755B9OtherMEDICARE