1992243976 NPI number — SAN ANTONIO ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, P.A.

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 1992243976 NPI number — SAN ANTONIO ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN ANTONIO ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, P.A.
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:
1992243976
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5282 MEDICAL DR
Provider Second Line Business Mailing Address:
SUITE # 316
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78229-6044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-696-7500
Provider Business Mailing Address Fax Number:
210-692-0248

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4025 E SOUTHCROSS BLVD
Provider Second Line Business Practice Location Address:
BUILDING 1, SUITE #5
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78222-3641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-337-8600
Provider Business Practice Location Address Fax Number:
210-337-8606
Provider Enumeration Date:
02/09/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MAZOCK
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
210-696-7500

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  19367 , 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)





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