Basic Information
| Provider Information | |||||||||
| NPI: | 1902274269 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | D V LISTENGARTEN MD PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10004 WURZBACH RD | ||||||||
| Address2: | 332 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138592978 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8550 HUEBNER RD | ||||||||
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| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105415300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2015 | ||||||||
| LastUpdateDate: | 09/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | LISTENGARTEN | ||||||||
| AuthorizedOfficialFirstName: | DMITRY | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7138592978 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | M0152 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 212157603 | 05 | TX | MEDICAID |