Basic Information
| Provider Information | |||||||||
| NPI: | 1710095302 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANCER CARE NETWORK OF SOUTH TEXAS PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FREDERICKSBURG-S.A.TUMOR & BLOOD | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 100 NE LOOP 410 | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782164700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102426541 | ||||||||
| FaxNumber: | 2102125136 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 W SCHUBERT ST | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786243847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102426541 | ||||||||
| FaxNumber: | 2102125136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 10/20/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GORDON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2105456972 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 00U40Q | 01 | TX | BLUECROSS/BLUESHIELD TX | OTHER | 109514302 | 05 | TX | MEDICAID |