Provider Demographics
NPI:1174604763
Name:CLINICA FAMILIAR SAN JOSE, PA
Entity type:Organization
Organization Name:CLINICA FAMILIAR SAN JOSE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:KUTUGATA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:956-969-2904
Mailing Address - Street 1:8030 FM 1015 STE B
Mailing Address - Street 2:
Mailing Address - City:MERCEDES
Mailing Address - State:TX
Mailing Address - Zip Code:78570-4809
Mailing Address - Country:US
Mailing Address - Phone:956-825-9757
Mailing Address - Fax:956-825-9125
Practice Address - Street 1:8030 N FM 1015 STE B
Practice Address - Street 2:
Practice Address - City:MERCEDES
Practice Address - State:TX
Practice Address - Zip Code:78570-4809
Practice Address - Country:US
Practice Address - Phone:956-825-9757
Practice Address - Fax:956-825-9125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTA03917207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117223100OtherVALLEY HEALTH PLANS
TX8U4260OtherBC/BS OF TEXAS
TX176879802Medicaid
TX176879801Medicaid
TX176879801Medicaid
TXE14221Medicare UPIN