Provider Demographics
NPI:1639194046
Name:SOULAS, MOISES MATEO JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MOISES
Middle Name:MATEO
Last Name:SOULAS
Suffix:JR
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 1:3100 AVENUE E
Mailing Address - Street 2:
Mailing Address - City:HONDO
Mailing Address - State:TX
Mailing Address - Zip Code:78861-3534
Mailing Address - Country:US
Mailing Address - Phone:830-426-7947
Mailing Address - Fax:830-426-7860
Practice Address - Street 1:8406 FM 471 S
Practice Address - Street 2:
Practice Address - City:CASTROVILLE
Practice Address - State:TX
Practice Address - Zip Code:78009-5315
Practice Address - Country:US
Practice Address - Phone:830-426-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8135208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX036042201Medicaid
TX8F2325Medicare ID - Type Unspecified
TX036042201Medicaid