Provider Demographics
NPI:1174653141
Name:PALACIOS, J. JAVIER (L-SA)
Entity type:Individual
Prefix:MR
First Name:J.
Middle Name:JAVIER
Last Name:PALACIOS
Suffix:
Gender:M
Credentials:L-SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9205
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78766-9205
Mailing Address - Country:US
Mailing Address - Phone:512-467-0989
Mailing Address - Fax:512-323-9703
Practice Address - Street 1:1910 W SAINT JOHNS AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-2241
Practice Address - Country:US
Practice Address - Phone:512-467-0989
Practice Address - Fax:512-323-9703
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00280208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0032LFOtherBCBS