Basic Information
| Provider Information | |||||||||
| NPI: | 1164836532 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REID | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 113 PLEASANT VALLEY DR | ||||||||
| Address2: | STE 210 | ||||||||
| City: | BOERNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780065683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302674575 | ||||||||
| FaxNumber: | 8302674575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 WONDER WORLD DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786667558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123963911 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2014 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R2209 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 373957501 | 05 | TX | MEDICAID |