Provider Demographics
NPI:1578913810
Name:MALDONADO, NICOLE CAVAZOS (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CAVAZOS
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 THOUSAND OAKS DR STE 23
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-3347
Mailing Address - Country:US
Mailing Address - Phone:210-920-3129
Mailing Address - Fax:210-490-8355
Practice Address - Street 1:2950 THOUSAND OAKS DR STE 23
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-3347
Practice Address - Country:US
Practice Address - Phone:210-920-3129
Practice Address - Fax:210-490-8355
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8912T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3746141-01Medicaid