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General NPI Number Information
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NPI Number | 1467803064
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Entity Type | Individual
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Provider Name | PRESTON JOHN PANICCO DPM
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Gender | Male
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Dates
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Enumeration Date | 06/24/2016
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Last Update Date | 09/17/2020
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Provider Practice Location Address
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Address Line | 14615 SAN PEDRO AVE STE 160
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City | SAN ANTONIO
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State | TX
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Zip | 78232-4364
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Country | US
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Telephone | 210-899-1026
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Fax | 210-490-1878
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Provider Business Mailing Address
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Address Line | 8042 WURZBACH RD STE 450
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City | SAN ANTONIO
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State | TX
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Zip | 78229-3808
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Country | US
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Telephone | 210-761-2185
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Fax | 702-734-4900
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 59.000613
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 2045
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License Number State | NV
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