Provider Demographics
NPI:1851341879
Name:SOUTHEAST SOUTH TEXAS CENTER FOR PEDIATRIC CARE
Entity Type:Organization
Organization Name:SOUTHEAST SOUTH TEXAS CENTER FOR PEDIATRIC CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:DALUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-576-0533
Mailing Address - Street 1:4212 E SOUTHCROSS BLVD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78222-3735
Mailing Address - Country:US
Mailing Address - Phone:210-576-0533
Mailing Address - Fax:210-226-4676
Practice Address - Street 1:1954 E HOUSTON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78202-2951
Practice Address - Country:US
Practice Address - Phone:210-576-0533
Practice Address - Fax:210-226-4676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty