Healthcare Provider Details

I. General information

NPI: 1891774816
Provider Name (Legal Business Name): MANUEL TREVINO DE LOS SANTOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8318 ANCIENT OAKS
SAN ANTONIO TX
78255-3504
US

IV. Provider business mailing address

8318 ANCIENT OAKS
SAN ANTONIO TX
78255-3504
US

V. Phone/Fax

Practice location:
  • Phone: 210-698-2172
  • Fax: 210-698-3778
Mailing address:
  • Phone: 210-698-2172
  • Fax: 210-698-3778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number17206
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: