Basic Information
| Provider Information | |||||||||
| NPI: | 1003018086 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUESADA | ||||||||
| FirstName: | MARIO | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1203E ALTON GLOOR BLVD | ||||||||
| Address2: | |||||||||
| City: | BROWNSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785263831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565442663 | ||||||||
| FaxNumber: | 9565422366 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 E ALTON GLOOR BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BROWNSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785263831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565442663 | ||||||||
| FaxNumber: | 9565422366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2007 | ||||||||
| LastUpdateDate: | 10/07/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XP3100X | MD200497 | LA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 207XS0114X | 13888 | NV | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XS0114X | Q1711 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1237710 | 05 | LA | MEDICAID |