1205904083 NPI number — STONE OAK SOUTH TEXAS CENTER FOR PEDIATRIC CARE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205904083 NPI number — STONE OAK SOUTH TEXAS CENTER FOR PEDIATRIC CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STONE OAK SOUTH TEXAS CENTER FOR PEDIATRIC CARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1205904083
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1954 E HOUSTON ST
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78202-2951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-576-0533
Provider Business Mailing Address Fax Number:
210-226-4676

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 STONE OAK LOOP
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:
78258-3391
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-576-0533
Provider Business Practice Location Address Fax Number:
210-226-4676
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DALUZ
Authorized Official First Name:
LISA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
210-576-0533

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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