Basic Information
Provider Information | |||||||||
NPI: | 1174507776 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLOND | ||||||||
FirstName: | CARL | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7142 SAN PEDRO AVE STE 120 | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782166256 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2106615622 | ||||||||
FaxNumber: | 2107986811 | ||||||||
Practice Location | |||||||||
Address1: | 2391 NE LOOP 410 STE 405 | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782175675 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2106547326 | ||||||||
FaxNumber: | 2105908232 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2005 | ||||||||
LastUpdateDate: | 08/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | F8413 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 390001456 | 01 | TX | MEDICARE RAILROAD | OTHER | 119151201 | 05 | TX |   | MEDICAID |