Provider Demographics
NPI:1740445758
Name:ROA, MARIO RIZALINO BASCON JR (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO RIZALINO
Middle Name:BASCON
Last Name:ROA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 TEXAS AVE S STE 100
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-3329
Mailing Address - Country:US
Mailing Address - Phone:979-690-4878
Mailing Address - Fax:979-690-4879
Practice Address - Street 1:4421 HIGHWAY 6 S STE 100
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6176
Practice Address - Country:US
Practice Address - Phone:979-731-5200
Practice Address - Fax:979-731-5210
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-20
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN7865207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX280666302Medicaid
TXTXB119601Medicare PIN