Healthcare Provider Details

I. General information

NPI: 1316268717
Provider Name (Legal Business Name): ANDREW JATSKIV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2010
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MEDICAL DR
SAN ANTONIO TX
78229
US

IV. Provider business mailing address

8811 VILLAGE DR
SAN ANTONIO TX
78217-5415
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-4000
  • Fax:
Mailing address:
  • Phone: 210-297-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberP7472
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: