Healthcare Provider Details

I. General information

NPI: 1629032990
Provider Name (Legal Business Name): KELLY S. RUEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4647 MEDICAL DR
SAN ANTONIO TX
78229-4403
US

IV. Provider business mailing address

PO BOX 87
SAN ANTONIO TX
78291-0087
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-3144
  • Fax: 210-358-8536
Mailing address:
  • Phone: 210-358-9172
  • Fax: 210-358-9183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL4684
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: