Healthcare Provider Details

I. General information

NPI: 1487235040
Provider Name (Legal Business Name): MICHAEL REIDAR DYBDAL-HARGREAVES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8210 CALLAGHAN RD
SAN ANTONIO TX
78230-4775
US

IV. Provider business mailing address

8210 CALLAGHAN RD
SAN ANTONIO TX
78230-4775
US

V. Phone/Fax

Practice location:
  • Phone: 210-233-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberV9301
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: