Provider Demographics
NPI:1629351150
Name:GILES, SERGIO O (LSA, CSA, CSFA)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:O
Last Name:GILES
Suffix:
Gender:M
Credentials:LSA, CSA, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8428 WHIPPOORWILL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-1996
Mailing Address - Country:US
Mailing Address - Phone:817-713-8905
Mailing Address - Fax:817-394-1427
Practice Address - Street 1:8428 WHIPPOORWILL DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123
Practice Address - Country:US
Practice Address - Phone:817-713-8905
Practice Address - Fax:817-394-1427
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00564246ZC0007X, 246ZC0007X, 246ZC0007X
DCSA0092246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
3143OtherCERTIFIED SURGICAL ASSISTANT
183346OtherCERTIFIED SURGICAL FIRST ASSISTANT
TXSA00564OtherLICENSE SURGICAL ASSISTANT