Basic Information
| Provider Information | |||||||||
| NPI: | 1265439079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERRITANO | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3066 E COMMERCE ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782201013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102337000 | ||||||||
| FaxNumber: | 2102776387 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 CAMDEN ST | ||||||||
| Address2: | STE. 601 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782152012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102337000 | ||||||||
| FaxNumber: | 2102364110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | K5375 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 151537103 | 05 | TX | MEDICAID |