Basic Information
Provider Information | |||||||||
NPI: | 1770563173 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TALLEY | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
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: | 2105825522 | ||||||||
Practice Location | |||||||||
Address1: | 12709 TOEPPERWEIN RD | ||||||||
Address2: | SUITE#206 | ||||||||
City: | LIVE OAK | ||||||||
State: | TX | ||||||||
PostalCode: | 782333258 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2105648000 | ||||||||
FaxNumber: | 2105907945 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/20/2006 | ||||||||
LastUpdateDate: | 08/26/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | J5920 | TX | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 117314802 | 05 | TX |   | MEDICAID |