Basic Information
| Provider Information | |||||||||
| NPI: | 1013055813 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANTILLAN-GOMEZ | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9722342987 | ||||||||
| Practice Location | |||||||||
| Address1: | 4411 MEDICAL DR | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105955300 | ||||||||
| FaxNumber: | 2105955301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 04/11/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | M8316 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 188777003 | 05 | TX | MEDICAID | P01701266 | 01 | TX | RAILROAD | OTHER | 8CH834 | 01 | TX | BCBS | OTHER | 188777002 | 05 | TX | MEDICAID | 206018803 | 05 | TX | MEDICAID |