Healthcare Provider Details

I. General information

NPI: 1548283385
Provider Name (Legal Business Name): BAKTHAVATHSALAM S ATHREYA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 W MARTIN ST
SAN ANTONIO TX
78207-0903
US

IV. Provider business mailing address

7703 FLOYD CURL DR
SAN ANTONIO TX
78229-3901
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-3555
  • Fax:
Mailing address:
  • Phone: 210-358-3555
  • Fax: 210-226-3610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG4520
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: