Provider Demographics
NPI:1689677916
Name:MAYORAL, JAIME LOPEZ (MD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:LOPEZ
Last Name:MAYORAL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1200 BROOKLYN AVE
Mailing Address - Street 2:STE 150
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-4803
Mailing Address - Country:US
Mailing Address - Phone:210-212-4114
Mailing Address - Fax:210-212-4012
Practice Address - Street 1:1200 BROOKLYN AVE.
Practice Address - Street 2:STE 150
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4815
Practice Address - Country:US
Practice Address - Phone:210-212-4114
Practice Address - Fax:210-212-4012
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2012-08-13
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Provider Licenses
StateLicense IDTaxonomies
TXJ9199208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117142303Medicaid
TXE77356Medicare UPIN
TX117142303Medicaid