Provider Demographics
NPI:1124629522
Name:CARCAMO, JOSE REYNALDO JR
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:REYNALDO
Last Name:CARCAMO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1544 W MISTLETOE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78201-5445
Mailing Address - Country:US
Mailing Address - Phone:210-542-3069
Mailing Address - Fax:
Practice Address - Street 1:18568 TEXAS 46
Practice Address - Street 2:SUITE 1001
Practice Address - City:SPRING BRANCH
Practice Address - State:TX
Practice Address - Zip Code:78070
Practice Address - Country:US
Practice Address - Phone:830-438-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1018465207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty