Basic Information
| Provider Information | |||||||||
| NPI: | 1215970843 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEEP | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1045 CENTRAL PKWY N | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782325085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105369591 | ||||||||
| FaxNumber: | 9044252949 | ||||||||
| Practice Location | |||||||||
| Address1: | 414 NAVARRO ST | ||||||||
| Address2: | STE 809 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782052516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102254810 | ||||||||
| FaxNumber: | 8553927989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 11/18/2016 | ||||||||
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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 | 207Q00000X | K9254 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01665575 | 01 | TX | RR MEDICARE | OTHER | K9254 | 01 | TX | TEXAS LICENSE NUMBER | OTHER | 046371306 | 05 | TX | MEDICAID |