Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0129X | Vascular Surgeon | G3280 | TX |
NPI | 1104824184 |
---|---|
Provider Name | Dr. Jorge Luis De La Garza |
First Address | Mcallen, TX 78504-0385 |
Second Address | Mcallen, TX 78501-2920 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/07/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8442B9 | BLUE CROSS BLUE SHIELD (01) | TX |
A002 | TRICARE (01) | TX |
F60141 | (02) | TX |