Healthcare Provider Details

I. General information

NPI: 1811995780
Provider Name (Legal Business Name): JORGE SAN MARTIN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N SAN SABA SUITE 100
SAN ANTONIO TX
78207-3154
US

IV. Provider business mailing address

315 N SAN SABA SUITE 100
SAN ANTONIO TX
78207-3154
US

V. Phone/Fax

Practice location:
  • Phone: 210-271-7575
  • Fax:
Mailing address:
  • Phone: 210-271-7575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2386TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: