Healthcare Provider Details

I. General information

NPI: 1770530974
Provider Name (Legal Business Name): ITALO AUGUSTO SAMANO PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4242 MEDICAL DR SUITE 6300
SAN ANTONIO TX
78229-5640
US

IV. Provider business mailing address

3019 FALL WAY DR
SAN ANTONIO TX
78247-3233
US

V. Phone/Fax

Practice location:
  • Phone: 210-614-8400
  • Fax: 210-614-8165
Mailing address:
  • Phone: 210-495-6346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number23724
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: