Basic Information
| Provider Information | |||||||||
| NPI: | 1851403729 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PERSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | WESLEY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 SPURS LANE | ||||||||
| Address2: | 310 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782401679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105587025 | ||||||||
| FaxNumber: | 2105584664 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 SPURS LANE | ||||||||
| Address2: | 310 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782401679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105587025 | ||||||||
| FaxNumber: | 2105584664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 11/05/2018 | ||||||||
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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 | 2082S0105X | J9536 | TX | N | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand | 208200000X | J9536 | TX | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 189324001 | 05 | TX | MEDICAID | 189324002 | 05 | TX | MEDICAID |