Basic Information
| Provider Information | |||||||||
| NPI: | 1871835983 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAWKINSON | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3551 ROGER BROOKE DR | ||||||||
| Address2: | |||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038870998 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3551 ROGER BROOK DR | ||||||||
| Address2: | SAN ANTONIO MILITARY MEDICAL CENTER | ||||||||
| City: | JBSA FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782346200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109161242 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2013 | ||||||||
| LastUpdateDate: | 04/27/2016 | ||||||||
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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 | 208D00000X | 0101257332 | VA | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 39020000X | 01 | TX | UNLICENSED | OTHER |