Basic Information
Provider Information | |||||||||
NPI: | 1346285772 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UROLOGY SAN ANTONIO P A | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7909 FREDERICKSBURG RD | ||||||||
Address2: | SUITE #110 | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782293425 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2106144544 | ||||||||
FaxNumber: | 2106793724 | ||||||||
Practice Location | |||||||||
Address1: | 18915 MEISNER DR | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782584223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2104995158 | ||||||||
FaxNumber: | 2106793730 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2006 | ||||||||
LastUpdateDate: | 10/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VASSAR | ||||||||
AuthorizedOfficialFirstName: | GEORGE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2106144544 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 10/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X |   | TX | N |   | Laboratories | Clinical Medical Laboratory |   | 208800000X |   | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 1346285772 | 01 | TX | NPI | OTHER | 084053002 | 05 | TX |   | MEDICAID | 084053001 | 05 | TX |   | MEDICAID |