Basic Information
| Provider Information | |||||||||
| NPI: | 1669433173 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LISTENGARTEN | ||||||||
| FirstName: | DMITRY | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8109 FREDERICKSBURG RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105758229 | ||||||||
| FaxNumber: | 2105758127 | ||||||||
| Practice Location | |||||||||
| Address1: | 8550 HUEBNER ROAD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105415300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2006 | ||||||||
| LastUpdateDate: | 08/31/2015 | ||||||||
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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 | 2084P0800X | 34057 | AZ | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | M0152 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 8CH279 | 01 | TX | BCBS | OTHER | 8DJ858 | 01 | TX | BCBS | OTHER | 942236 | 05 | AZ | MEDICAID | 212157603 | 05 | TX | MEDICAID |