Basic Information
| Provider Information | |||||||||
| NPI: | 1306814942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GURWITZ | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | BLUMENTHAL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLUMENTHAL | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4499 MEDICAL DR | ||||||||
| Address2: | SUITE 119 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106149400 | ||||||||
| FaxNumber: | 2106149244 | ||||||||
| Practice Location | |||||||||
| Address1: | 4499 MEDICAL DR | ||||||||
| Address2: | SUITE 119 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106149400 | ||||||||
| FaxNumber: | 2106149244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 08/26/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | J8257 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 042201601 | 05 | TX | MEDICAID |