Healthcare Provider Details

I. General information

NPI: 1578673166
Provider Name (Legal Business Name): WILLIAM CHAD CRAGUN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16110 VIA SHAVANO
SAN ANTONIO TX
78249-2380
US

IV. Provider business mailing address

16110 VIA SHAVANO
SAN ANTONIO TX
78249-2380
US

V. Phone/Fax

Practice location:
  • Phone: 210-615-7171
  • Fax: 210-615-6793
Mailing address:
  • Phone: 210-615-7171
  • Fax: 210-615-6793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number7454874-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberN4363
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number23843
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: