Provider Demographics
NPI:1861498966
Name:DE JUANA, CARLOS P (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:P
Last Name:DE JUANA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:110 E SAVANNAH AVE
Mailing Address - Street 2:BLDG C101
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78503-1242
Mailing Address - Country:US
Mailing Address - Phone:956-686-8357
Mailing Address - Fax:956-686-5030
Practice Address - Street 1:110 E SAVANNAH AVE
Practice Address - Street 2:BLDG C101
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1242
Practice Address - Country:US
Practice Address - Phone:956-686-8357
Practice Address - Fax:956-686-5030
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXE3679208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129283101Medicaid
TX129283101Medicaid
TX84T343Medicare ID - Type Unspecified