Healthcare Provider Details

I. General information

NPI: 1568492387
Provider Name (Legal Business Name): VINOD KUMAR GIDVANI-DIAZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 MEDICAL DR STE 540
SAN ANTONIO TX
78229-3755
US

IV. Provider business mailing address

42 SENDERO WOODS
FAIR OAKS RANCH TX
78015-8370
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-7727
  • Fax: 210-916-9319
Mailing address:
  • Phone: 210-557-3172
  • Fax: 210-916-9319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberM7212
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: