Provider Demographics
NPI:1366571556
Name:IVAN MEDEROS, M.D.,P.A.
Entity type:Organization
Organization Name:IVAN MEDEROS, M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-795-8297
Mailing Address - Street 1:PO BOX 450748
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-0748
Mailing Address - Country:US
Mailing Address - Phone:956-795-8297
Mailing Address - Fax:956-794-8888
Practice Address - Street 1:1710 E.SAUNDERS
Practice Address - Street 2:SUITE B375
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041
Practice Address - Country:US
Practice Address - Phone:956-795-8297
Practice Address - Fax:956-794-8888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG48616Medicare UPIN
TX00271TMedicare ID - Type Unspecified