1922716794 NPI number — DR. JEFERSON VASCONCELLOS MARADEI MD

Table of content: DR. JEFERSON VASCONCELLOS MARADEI MD (NPI 1922716794)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922716794 NPI number — DR. JEFERSON VASCONCELLOS MARADEI MD

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
VASCONCELLOS MARADEI

Provider First Name:
JEFERSON

Provider Middle Name:

Provider Name Prefix Text:
DR.

Provider Name Suffix Text:

Provider Credential Text:
MD

Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922716794

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
03/05/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
413 UMAR AVE

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
MCALLEN

Provider Business Mailing Address State Name:
TX

Provider Business Mailing Address Postal Code:
78504-1972

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
210-322-6792

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23103 IH 10 W STE 111

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
SAN ANTONIO

Provider Business Practice Location Address State Name:
TX

Provider Business Practice Location Address Postal Code:
78257-1766

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
210-571-7546

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
11/10/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 208200000X , with the licence number: PENDING , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Taxonomy code: 2086S0122X , with the licence number: PENDING , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .