Provider Demographics
NPI:1699950691
Name:AMISTAD SURGICAL & LAPAROSCOPIC CLINIC
Entity type:Organization
Organization Name:AMISTAD SURGICAL & LAPAROSCOPIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:MAEDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-774-4099
Mailing Address - Street 1:517 N BEDELL AVE
Mailing Address - Street 2:
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840-4807
Mailing Address - Country:US
Mailing Address - Phone:830-774-4099
Mailing Address - Fax:830-774-0890
Practice Address - Street 1:517 N BEDELL AVE
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-4807
Practice Address - Country:US
Practice Address - Phone:830-774-4099
Practice Address - Fax:830-774-0890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1719261QC1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0062NPOtherBCBSTX
TX00272YMedicare PIN