MEDICARE: MAYRALIS DE JESUS MD

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	207Q00000X	Family Medicine Physician	R6767	TX

General Provider Information

NPI Number	:	1568857423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYRALIS DE JESUS MD

Provider Business Mailing Address
First Line	:	2455 NE LOOP 410 STE 100
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-5650
Country	:	US
Telephone Number	:	210-599-6000
Fax Number	:

Provider Business Practice Location Address
First Line	:	122 SAINT CLOUD RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78228-5009
Country	:	US
Telephone Number	:	726-240-6949
Fax Number	:

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

Provider Enumeration Date	:	03/30/2015
Last Update Date	:	02/21/2024

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