MEDICARE: MR. ISRAEL D. CUSTODIO PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA01549	TX

General Provider Information

NPI Number	:	1366570087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ISRAEL D. CUSTODIO PA-C

Provider Business Mailing Address
First Line	:	4805 FREDERICKSBURG RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3627
Country	:	US
Telephone Number	:	210-979-7999
Fax Number	:	210-798-2457

Provider Business Practice Location Address
First Line	:	4805 FREDERICKSBURG RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3627
Country	:	US
Telephone Number	:	210-979-7999
Fax Number	:	210-798-2457

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	07/08/2007

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