Basic Information
| Provider Information | |||||||||
| NPI: | 1629391842 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIABETES AND GLANDULAR DISEASE CLINIC CERTIFIED DIABETES EDUCATION CEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5107 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106148612 | ||||||||
| FaxNumber: | 2106151666 | ||||||||
| Practice Location | |||||||||
| Address1: | 5107 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106148612 | ||||||||
| FaxNumber: | 2106151666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2010 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | BAGWELL | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | LABORATORY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2106155541 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MT | ||||||||
| NPICertificationDate: | 06/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 121762202 | 05 | TX | MEDICAID |