Provider Demographics
NPI:1750682639
Name:MARIO R ROA JR MD PA
Entity Type:Organization
Organization Name:MARIO R ROA JR MD PA
Other - Org Name:MARIO B ROA JR MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARKER
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:940-759-6126
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:MUENSTER
Mailing Address - State:TX
Mailing Address - Zip Code:76252-0370
Mailing Address - Country:US
Mailing Address - Phone:940-759-2226
Mailing Address - Fax:940-759-2385
Practice Address - Street 1:509 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:MUENSTER
Practice Address - State:TX
Practice Address - Zip Code:76252-2425
Practice Address - Country:US
Practice Address - Phone:940-759-2226
Practice Address - Fax:940-759-2385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-09
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN7865207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX280665501Medicaid
TX280665501Medicaid