Healthcare Provider Details

I. General information

NPI: 1538175443
Provider Name (Legal Business Name): MARSHALL BRANDON PACKARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 NAVARRO ST STE 502
SAN ANTONIO TX
78205-2580
US

IV. Provider business mailing address

11844 BANDERA RD PMB 452
HELOTES TX
78023-4132
US

V. Phone/Fax

Practice location:
  • Phone: 210-223-1145
  • Fax: 210-615-7619
Mailing address:
  • Phone: 210-223-1145
  • Fax: 210-615-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL1419
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License NumberL1419
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: