Healthcare Provider Details

I. General information

NPI: 1699898643
Provider Name (Legal Business Name): GRADY DEE ALSABROOK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N MAIN AVENUE
SAN ANTONIO TX
78205-1204
US

IV. Provider business mailing address

610 NORTH MAIN, SECOND FLOOR
SAN ANTONIO TX
78205-1204
US

V. Phone/Fax

Practice location:
  • Phone: 210-225-6508
  • Fax: 210-225-1486
Mailing address:
  • Phone: 210-237-4444
  • Fax: 210-828-5731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM6496
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberM6496
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: