Provider Demographics
NPI:1912211913
Name:AMISTAD MEDICAL PROFESSIONALS
Entity Type:Organization
Organization Name:AMISTAD MEDICAL PROFESSIONALS
Other - Org Name:VAL VERDE HEALTH CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SENIOR DIRECTOR OF OUPATIENT SERVIC
Authorized Official - Prefix:
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-774-4580
Mailing Address - Street 1:PO BOX 437
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78292-0437
Mailing Address - Country:US
Mailing Address - Phone:210-558-6288
Mailing Address - Fax:
Practice Address - Street 1:1200 N BEDELL AVE
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-4491
Practice Address - Country:US
Practice Address - Phone:830-774-4580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-02
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX281839501Medicaid
TX281839501Medicaid