Provider Demographics
NPI:1457384158
Name:JAIME L MAYORAL MD PA
Entity type:Organization
Organization Name:JAIME L MAYORAL MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:L
Authorized Official - Last Name:MAYORAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-212-4114
Mailing Address - Street 1:PO BOX 596
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78292-0596
Mailing Address - Country:US
Mailing Address - Phone:210-212-4114
Mailing Address - Fax:210-212-4012
Practice Address - Street 1:315 N SAN SABA
Practice Address - Street 2:SUITE 1240
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3154
Practice Address - Country:US
Practice Address - Phone:210-212-4114
Practice Address - Fax:210-212-4012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9199208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160960401Medicaid
TX00662VMedicare PIN