1316915119 NPI number — SIEGFRIED PUEBLITZ MD

Table of content: SIEGFRIED PUEBLITZ MD (NPI 1316915119)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316915119 NPI number — SIEGFRIED PUEBLITZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUEBLITZ
Provider First Name:
SIEGFRIED
Provider Middle Name:
Provider Name Prefix Text:
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:
1316915119
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6918 CAMP BULLIS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78256-2236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-497-0445
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 E SAUNDERS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAREDO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78041-5474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-617-4445
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/09/2006

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: 208D00000X , with the licence number:  J2746 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: J2746 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 131091408 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".