Healthcare Provider Details

I. General information

NPI: 1790928919
Provider Name (Legal Business Name): HEDY SETYADI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2009
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11212 STATE HIGHWAY 151 STE 320
SAN ANTONIO TX
78251-4502
US

IV. Provider business mailing address

11212 STATE HIGHWAY 151 STE 320
SAN ANTONIO TX
78251-4502
US

V. Phone/Fax

Practice location:
  • Phone: 830-276-2600
  • Fax:
Mailing address:
  • Phone: 830-276-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME127088
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberP2785
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: