Provider Demographics
NPI:1629683206
Name:ELIZONDO, RAUL III
Entity Type:Individual
Prefix:DR
First Name:RAUL
Middle Name:
Last Name:ELIZONDO
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E FM 495
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589-3710
Mailing Address - Country:US
Mailing Address - Phone:956-283-7880
Mailing Address - Fax:956-283-0225
Practice Address - Street 1:100 E FM 495
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-3710
Practice Address - Country:US
Practice Address - Phone:956-283-7880
Practice Address - Fax:956-283-0225
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63204183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist