Provider Demographics
NPI:1740775394
Name:PALENCIA PACHECO, DAIVYD ALEXANDER (MD)
Entity type:Individual
Prefix:
First Name:DAIVYD
Middle Name:ALEXANDER
Last Name:PALENCIA PACHECO
Suffix:
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 1:7703 FLOYD CURL DR # 7742
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3900
Mailing Address - Country:US
Mailing Address - Phone:210-567-5711
Mailing Address - Fax:
Practice Address - Street 1:56 FRANKLIN ST STE 1
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1281
Practice Address - Country:US
Practice Address - Phone:203-709-6479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10065359390200000X
CTBP10065359390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program