Healthcare Provider Details

I. General information

NPI: 1801890157
Provider Name (Legal Business Name): RICARDO LUIS CUELLAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7430 BARLITE BLVD SUITE 104
SAN ANTONIO TX
78224-1365
US

IV. Provider business mailing address

31109 KNOTTY GRV
FAIR OAKS RANCH TX
78015-4305
US

V. Phone/Fax

Practice location:
  • Phone: 210-977-9080
  • Fax: 210-977-8480
Mailing address:
  • Phone: 210-977-9080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberL6336
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: