Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | L6508 | TX |
NPI | 1003856089 |
---|---|
Provider Name | Dr. Rolando R Maldonado I |
First Address | Houston, TX 77019-2002 |
Second Address | Houston, TX 77019-2002 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/06/2006 |
Last Update Date | 03/02/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1673922302 | (05) | TX |
167392302 | MEDICAID EPSDT (01) | TX |