Provider Demographics
NPI:1124177654
Name:MAYANS, JOSE A (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:MAYANS
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 1:907 WEST 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-4305
Mailing Address - Country:US
Mailing Address - Phone:432-333-1324
Mailing Address - Fax:432-337-7628
Practice Address - Street 1:907 W 2ND ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-4305
Practice Address - Country:US
Practice Address - Phone:432-333-1324
Practice Address - Fax:432-337-7628
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6029207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0808248-01Medicaid
TX88450KMedicare PIN
TX0808248-01Medicaid