Provider Demographics
NPI:1790960524
Name:JOSE ROEL MALDONADO JR MD PA
Entity Type:Organization
Organization Name:JOSE ROEL MALDONADO JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:ROEL
Authorized Official - Last Name:MALDONADO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:956-791-8008
Mailing Address - Street 1:PO BOX 452309
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-0057
Mailing Address - Country:US
Mailing Address - Phone:956-791-8008
Mailing Address - Fax:956-791-8098
Practice Address - Street 1:6828 SPRINGFIELD AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-2286
Practice Address - Country:US
Practice Address - Phone:956-791-8008
Practice Address - Fax:956-791-8098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00950XMedicare PIN