Healthcare Provider Details

I. General information

NPI: 1144715384
Provider Name (Legal Business Name): MARYAM ELMI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7979 WURZBACH 6TH FLOOR, ZELLER BLDG
SAN ANTONIO TX
78229
US

IV. Provider business mailing address

8431 FREDERICKSBURG ROAD 1ST FLOOR
SAN ANTONIO TX
78229
US

V. Phone/Fax

Practice location:
  • Phone: 210-450-5990
  • Fax: 210-450-1747
Mailing address:
  • Phone: 210-450-9000
  • Fax: 210-450-4621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberR6389
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR6389
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: