Provider Demographics
NPI:1629136130
Name:OBALLO, FELINO CANENDO (MD)
Entity Type:Individual
Prefix:
First Name:FELINO
Middle Name:CANENDO
Last Name:OBALLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9901 VALDERRAMA DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-3847
Mailing Address - Country:US
Mailing Address - Phone:830-672-7581
Mailing Address - Fax:830-672-8481
Practice Address - Street 1:1110 N SARAH DEWITT DR
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:TX
Practice Address - Zip Code:78629-3311
Practice Address - Country:US
Practice Address - Phone:830-672-7581
Practice Address - Fax:830-672-2401
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8596208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00MC06OtherMC
TX8L5471OtherMC PTAN
TX114639101Medicaid
TX114639101Medicaid