Basic Information
| Provider Information | |||||||||
| NPI: | 1629062526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENA | ||||||||
| FirstName: | RAQUEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 650859 | ||||||||
| Address2: | DEPT 710 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097476240 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17448 HIGHWAY 3 STE 200 | ||||||||
| Address2: | |||||||||
| City: | WEBSTER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775984140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2816041300 | ||||||||
| FaxNumber: | 2817240225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | J4347 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 5478482 | 01 | TX | AETNA | OTHER | 105262303 | 05 | TX | MEDICAID | 8F6724 | 01 | TX | BCBS | OTHER | 87594Z | 01 | TX | HMO BLUE | OTHER |