Basic Information
| Provider Information | |||||||||
| NPI: | 1710988274 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WINAKUR | ||||||||
| FirstName: | JERALD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4410 MEDICAL DR | ||||||||
| Address2: | STE#100 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782296306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106144000 | ||||||||
| FaxNumber: | 2106149114 | ||||||||
| Practice Location | |||||||||
| Address1: | 4410 MEDICAL DR | ||||||||
| Address2: | STE#100 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782296306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106144000 | ||||||||
| FaxNumber: | 2106149114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 02/01/2010 | ||||||||
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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 | 207R00000X | E5645 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 097359601 | 05 | TX | MEDICAID | 110231947 | 01 | RAILROAD MEDICARE | OTHER |