Provider Demographics
NPI:1790778470
Name:INTERIANO, JOSE CARLOS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:CARLOS
Last Name:INTERIANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1631 NORTH LOOP W
Mailing Address - Street 2:#440
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008-1500
Mailing Address - Country:US
Mailing Address - Phone:713-861-8113
Mailing Address - Fax:713-861-6010
Practice Address - Street 1:1631 NORTH LOOP W
Practice Address - Street 2:#440
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1500
Practice Address - Country:US
Practice Address - Phone:713-861-8113
Practice Address - Fax:713-861-6010
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXH7434208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10014841OtherAMERIGROUP MEDICAID
TX00F74BOtherBLUE CROSS BLUE SHIELD
TX10014840OtherAMERIGROUP CHIP PROGRAM