Healthcare Provider Details

I. General information

NPI: 1144331083
Provider Name (Legal Business Name): W. BRENT GILLESPIE D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19222 STONEHUE STE 104
SAN ANTONIO TX
78258-3454
US

IV. Provider business mailing address

19222 STONEHUE STE 104
SAN ANTONIO TX
78258-3454
US

V. Phone/Fax

Practice location:
  • Phone: 210-490-6408
  • Fax: 210-490-6419
Mailing address:
  • Phone: 210-490-6408
  • Fax: 210-490-6419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1084
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number1084
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number1084
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: