Provider Demographics
NPI:1609039049
Name:ALCANTARA, MARIO ALBERTO (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:ALBERTO
Last Name:ALCANTARA
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 1:1200 BROOKLYN AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-0000
Mailing Address - Country:US
Mailing Address - Phone:210-212-4114
Mailing Address - Fax:210-212-4012
Practice Address - Street 1:1200 BROOKLYN AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212
Practice Address - Country:US
Practice Address - Phone:210-212-4114
Practice Address - Fax:210-212-4012
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9788208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197167301Medicaid
TX197167301Medicaid