Basic Information
| Provider Information | |||||||||
| NPI: | 1780627919 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAUER | ||||||||
| FirstName: | MIRIAM | ||||||||
| MiddleName: | CANTU | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CANTU | ||||||||
| OtherFirstName: | MIRIAM | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 333 N SANTA ROSA ST | ||||||||
| Address2: | SUITE D4023 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4692822711 | ||||||||
| FaxNumber: | 4692822609 | ||||||||
| Practice Location | |||||||||
| Address1: | 1434 E SONTERRA BLVD STE 105 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782584972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104793000 | ||||||||
| FaxNumber: | 2104793016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 03/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | K2410 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 111761604 | 05 | TX | MEDICAID | 1265475891 | 01 | TX | GROUP NPI | OTHER | 111761605 | 05 | TX | MEDICAID | 173321401 | 05 | TX | MEDICAID |