Provider Demographics
NPI:1679864383
Name:TORRES, MIGUEL
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:TORRES
Suffix:
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 1:5470 E LOOP 820
Mailing Address - Street 2:STE 110
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76119-6515
Mailing Address - Country:US
Mailing Address - Phone:817-536-6877
Mailing Address - Fax:817-535-5233
Practice Address - Street 1:5470 E LOOP 820
Practice Address - Street 2:STE 110
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76119-6515
Practice Address - Country:US
Practice Address - Phone:817-536-6877
Practice Address - Fax:817-535-5233
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11403247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010839101Medicaid
TX530531OtherBLUE CROSS BLUE SHIELD OF TX
TX010839102Medicaid
TX016703301Medicaid
TX016703301Medicaid