Provider Demographics
NPI:1386936912
Name:SEGOVIA, MARIO H (PTA)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:H
Last Name:SEGOVIA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 GOLIAD RD LOT 106
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78223-5600
Mailing Address - Country:US
Mailing Address - Phone:210-778-2111
Mailing Address - Fax:210-236-5288
Practice Address - Street 1:1904 GRANDSTAND DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-4508
Practice Address - Country:US
Practice Address - Phone:210-520-8070
Practice Address - Fax:210-521-7688
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2014205225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant