Provider Demographics
NPI:1285077081
Name:SOUTHERN TEXAS HEART AND VASCULAR CLINIC, PLLC
Entity type:Organization
Organization Name:SOUTHERN TEXAS HEART AND VASCULAR CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:DIEGO
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-653-0887
Mailing Address - Street 1:12709 TOEPPERWEIN RD STE 205
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3260
Mailing Address - Country:US
Mailing Address - Phone:210-653-0887
Mailing Address - Fax:210-653-0615
Practice Address - Street 1:12501 JUDSON RD STE 202
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-4117
Practice Address - Country:US
Practice Address - Phone:210-599-4086
Practice Address - Fax:210-655-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP0091207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12356656OtherCAQH