Healthcare Provider Details

I. General information

NPI: 1750394243
Provider Name (Legal Business Name): JASON E. MIRELES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 05/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 W MISTLETOE AVE
SAN ANTONIO TX
78228-5311
US

IV. Provider business mailing address

2430 W MISTLETOE AVE
SAN ANTONIO TX
78228-5311
US

V. Phone/Fax

Practice location:
  • Phone: 210-733-7179
  • Fax: 210-824-1813
Mailing address:
  • Phone: 210-733-7179
  • Fax: 210-824-1813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number1726
License Number StateTX

VIII. Authorized Official

Name: DR. JASON E MIRELES
Title or Position: PODIATRIST
Credential: DPM
Phone: 210-387-6231