Provider Demographics
NPI:1629566872
Name:RICO MESA, JUAN SIMON (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:SIMON
Last Name:RICO MESA
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 1:4502 MEDICAL DR # 78229
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4402
Mailing Address - Country:US
Mailing Address - Phone:210-358-3555
Mailing Address - Fax:
Practice Address - Street 1:4502 MEDICAL DRIVE, SAN ANTONIO, 78229
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:55901
Practice Address - Country:US
Practice Address - Phone:210-358-3555
Practice Address - Fax:210-702-4239
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program