Provider Demographics
NPI:1871850909
Name:MEDRANO, PEDRO
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:
Last Name:MEDRANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 N VERMONT AVE
Mailing Address - Street 2:SUITE #A
Mailing Address - City:MERCEDES
Mailing Address - State:TX
Mailing Address - Zip Code:78570-2519
Mailing Address - Country:US
Mailing Address - Phone:956-565-9438
Mailing Address - Fax:956-565-9398
Practice Address - Street 1:50 N VERMONT AVE
Practice Address - Street 2:SUITE #A
Practice Address - City:MERCEDES
Practice Address - State:TX
Practice Address - Zip Code:78570-2519
Practice Address - Country:US
Practice Address - Phone:956-565-9438
Practice Address - Fax:956-565-9398
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11420096429332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX281518502Medicaid
TX281518501Medicaid
TX6468090001Medicare NSC