Provider Demographics
NPI:1801825740
Name:MARIO PEREZ DO PA
Entity Type:Organization
Organization Name:MARIO PEREZ DO PA
Other - Org Name:POTEET FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:830-742-3637
Mailing Address - Street 1:8555 N STATE HIGHWAY 16
Mailing Address - Street 2:
Mailing Address - City:POTEET
Mailing Address - State:TX
Mailing Address - Zip Code:78065-4034
Mailing Address - Country:US
Mailing Address - Phone:830-742-3637
Mailing Address - Fax:830-742-3534
Practice Address - Street 1:8555 N STATE HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:POTEET
Practice Address - State:TX
Practice Address - Zip Code:78065-4034
Practice Address - Country:US
Practice Address - Phone:830-742-3637
Practice Address - Fax:830-742-3534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4526207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092352601Medicaid
TX171626801Medicaid
TX092352602Medicaid
TX458966Medicare Oscar/Certification
00355XMedicare PIN