Healthcare Provider Details

I. General information

NPI: 1962697649
Provider Name (Legal Business Name): M M ONTIVEROS MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 CAMDEN ST SUITE 102
SAN ANTONIO TX
78215-2012
US

IV. Provider business mailing address

311 CAMDEN ST SUITE 102
SAN ANTONIO TX
78215-2012
US

V. Phone/Fax

Practice location:
  • Phone: 210-281-9800
  • Fax: 210-281-1001
Mailing address:
  • Phone: 210-281-9800
  • Fax: 210-281-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberH5196
License Number StateTX

VIII. Authorized Official

Name: CHRIS MATHIS
Title or Position: OFFICE MANAGER
Credential:
Phone: 210-525-1668