1972500783 NPI number — GREGORIO ELIZONDO PEDROZA III MD

Table of content: GREGORIO ELIZONDO PEDROZA III MD (NPI 1972500783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972500783 NPI number — GREGORIO ELIZONDO PEDROZA III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEDROZA
Provider First Name:
GREGORIO
Provider Middle Name:
ELIZONDO
Provider Name Prefix Text:
Provider Name Suffix Text:
III
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:
1972500783
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8637 FREDERICKSBURG RD
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78240-1283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-617-4708
Provider Business Mailing Address Fax Number:
210-617-4075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13750 SAN PEDRO
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78232-4375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-490-9087
Provider Business Practice Location Address Fax Number:
210-496-1285
Provider Enumeration Date:
07/07/2005

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: 207R00000X , with the licence number:  K3388 , 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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