Healthcare Provider Details

I. General information

NPI: 1174569842
Provider Name (Legal Business Name): MARIO E RUIZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 04/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18126 PRESTONSHIRE
SAN ANTONIO TX
78258-4473
US

IV. Provider business mailing address

18126 PRESTONSHIRE
SAN ANTONIO TX
78258-4473
US

V. Phone/Fax

Practice location:
  • Phone: 210-844-7575
  • Fax: 210-493-8297
Mailing address:
  • Phone: 210-844-7575
  • Fax: 210-493-8297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberK1917
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: