Healthcare Provider Details

I. General information

NPI: 1255856472
Provider Name (Legal Business Name): DIEGO RAFAEL IRAVEDRA-GARCIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

IV. Provider business mailing address

2610 ERWIN RD
DURHAM NC
27705-3853
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberT2890
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2025-00788
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: