Provider Demographics
NPI:1881645497
Name:TOLOZA-LARSON, EILEEN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:MARIE
Last Name:TOLOZA-LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EILEEN
Other - Middle Name:MARIE
Other - Last Name:TOLOZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4352 JUNCTION HWY
Mailing Address - Street 2:
Mailing Address - City:INGRAM
Mailing Address - State:TX
Mailing Address - Zip Code:78025-5069
Mailing Address - Country:US
Mailing Address - Phone:830-367-7639
Mailing Address - Fax:
Practice Address - Street 1:551 HILL COUNTRY DR
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-6085
Practice Address - Country:US
Practice Address - Phone:830-896-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8979207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166152202Medicaid
TX8C1344Medicare PIN
TX166152202Medicaid
TXP00139841Medicare PIN