Provider Demographics
NPI:1972664613
Name:CHILDRENS CLINIC OF DIMMIT AND ZAVALA PA
Entity Type:Organization
Organization Name:CHILDRENS CLINIC OF DIMMIT AND ZAVALA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ABELARDO
Authorized Official - Middle Name:SABANGAN
Authorized Official - Last Name:DORIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-876-9870
Mailing Address - Street 1:403 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CARRIZO SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78834-3805
Mailing Address - Country:US
Mailing Address - Phone:830-876-9870
Mailing Address - Fax:830-876-3661
Practice Address - Street 1:403 S 7TH ST
Practice Address - Street 2:
Practice Address - City:CARRIZO SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:78834-3805
Practice Address - Country:US
Practice Address - Phone:830-876-9870
Practice Address - Fax:830-876-3661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
111931502OtherTHSTERS
TX1577750401Medicaid
673855Medicare ID - Type Unspecified