Healthcare Provider Details

I. General information

NPI: 1295197879
Provider Name (Legal Business Name): ELISSA PRADO GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELISSA CRISTINA PRADO

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12005 FM 2244 RD
AUSTIN TX
78738-6385
US

IV. Provider business mailing address

333 N SANTA ROSA ST
SAN ANTONIO TX
78207-3108
US

V. Phone/Fax

Practice location:
  • Phone: 512-225-0766
  • Fax:
Mailing address:
  • Phone: 210-704-3910
  • Fax: 210-704-4922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberS2785
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: