Provider Demographics
NPI:1619091295
Name:RICARDO DE LOS SANTOS, M.D.,P.A.
Entity Type:Organization
Organization Name:RICARDO DE LOS SANTOS, M.D.,P.A.
Other - Org Name:PEDIATRIC SPECIALTY CLINIC & LAB #2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:W
Authorized Official - Last Name:DE LOS SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-773-1103
Mailing Address - Street 1:2198 E. GARRISON ST.
Mailing Address - Street 2:STE. 1
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-5076
Mailing Address - Country:US
Mailing Address - Phone:830-773-1103
Mailing Address - Fax:830-757-8366
Practice Address - Street 1:2198 E. GARRISON ST.
Practice Address - Street 2:STE. 1
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-5076
Practice Address - Country:US
Practice Address - Phone:830-773-1103
Practice Address - Fax:830-757-8366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3442208000000X
TX45D0506351291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111923201Medicaid
TX363381001Medicaid
TXC15128Medicare UPIN
TX1104958081OtherNPI - EPPHC
TX8127J1Medicare ID - Type UnspecifiedEPPHC-GROUP
TX1104958081OtherNPI - EPPHC