Healthcare Provider Details

I. General information

NPI: 1366904492
Provider Name (Legal Business Name): BRIAN SO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2019
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3503 PAESANOS PKWY STE 101
SAN ANTONIO TX
78231-1225
US

IV. Provider business mailing address

3503 PAESANOS PKWY STE 101
SAN ANTONIO TX
78231-1225
US

V. Phone/Fax

Practice location:
  • Phone: 210-492-8922
  • Fax: 210-479-2010
Mailing address:
  • Phone: 210-492-8922
  • Fax: 210-479-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberT6044
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: