1427227602 NPI number — GERARDO QUEZADA MD

Table of content: GERARDO QUEZADA MD (NPI 1427227602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427227602 NPI number — GERARDO QUEZADA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUEZADA
Provider First Name:
GERARDO
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:
1427227602
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8109 FREDERICKSBURG RD
Provider Second Line Business Mailing Address:
PHYSICIAN PRACTICE SERVICES
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78229-3311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-575-6240
Provider Business Mailing Address Fax Number:
210-575-6280

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4410 MEDICAL DR
Provider Second Line Business Practice Location Address:
SUITE 540
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78229-3749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-575-6240
Provider Business Practice Location Address Fax Number:
210-575-6280
Provider Enumeration Date:
02/21/2008

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: 207RH0000X , with the licence number:  M7544 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: M7544 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0207X , with the licence number: M7544 , 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: 191616506 . This is a "CSHCN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8F10114 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 191616505 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8BX396 . This is a "BCBS TX" identifier . This identifiers is of the category "OTHER".




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