Healthcare Provider Details

I. General information

NPI: 1588804637
Provider Name (Legal Business Name): WALTER W. ROOT, M.D.P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 03/03/2009
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

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM6366
License Number StateTX

VIII. Authorized Official

Name: MRS. TAMMY FOUNTAIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 210-692-0224