1114162492 NPI number — RAUL ERNESTO LOAISIGA MD PA

Table of content: (NPI 1114162492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114162492 NPI number — RAUL ERNESTO LOAISIGA MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAUL ERNESTO LOAISIGA MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114162492
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4770 N EXPRESSWAY
Provider Second Line Business Mailing Address:
STE. 206
Provider Business Mailing Address City Name:
BROWNSVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78526-4165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-350-5500
Provider Business Mailing Address Fax Number:
956-350-4965

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4770 N EXPRESSWAY # 7783
Provider Second Line Business Practice Location Address:
STE 206
Provider Business Practice Location Address City Name:
BROWNSVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78526-4120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-350-5500
Provider Business Practice Location Address Fax Number:
956-350-4965
Provider Enumeration Date:
12/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LOAISIGA
Authorized Official First Name:
RAUL
Authorized Official Middle Name:
ERNESTO
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
956-350-5500

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  L0383 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 198528501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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