Healthcare Provider Details

I. General information

NPI: 1720342454
Provider Name (Legal Business Name): PERSONALIZED PRESCRIPTION PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 06/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7800 IH 10 WEST SUITE 612
SAN ANTONIO TX
78230
US

IV. Provider business mailing address

PO BOX 40116
SAN ANTONIO TX
78229-1116
US

V. Phone/Fax

Practice location:
  • Phone: 210-253-9947
  • Fax:
Mailing address:
  • Phone: 210-253-9947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208U00000X
TaxonomyClinical Pharmacology Physician
License NumberN2069
License Number StateTX

VIII. Authorized Official

Name: DR. REGINALD EWESUEDO
Title or Position: MEDICAL DIRECTOR
Credential: M.D
Phone: 210-625-1171