Provider Demographics
NPI:1720027881
Name:DE LA TORRE, MIGUEL ALBERTO (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ALBERTO
Last Name:DE LA TORRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3066 E COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78220-1013
Mailing Address - Country:US
Mailing Address - Phone:210-233-7000
Mailing Address - Fax:210-434-1704
Practice Address - Street 1:2810 DACY LN
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6322
Practice Address - Country:US
Practice Address - Phone:512-268-8900
Practice Address - Fax:512-268-2250
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5008207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4763796Medicaid
MID36747Medicare UPIN
MIOA36038009Medicare ID - Type Unspecified