=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457998494
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEXAS OAKS ORTHOPAEDIC AND SPORTS MEDICINE INSTITUTE, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2019
-----------------------------------------------------
Last Update Date | 12/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12103 HUEBNER RD
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78230-5000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-753-2663
-----------------------------------------------------
Fax | 210-617-7542
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12103 HUEBNER RD
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78230-5000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-753-2663
-----------------------------------------------------
Fax | 210-617-7542
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT / ORTHOPAEDIC SURGEON
-----------------------------------------------------
Name | DAVID M GONZALEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 210-753-2663
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------