Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081P2900X | Pain Medicine | M1395 | TX |
N | 225400000X | Rehabilitation Practitioner | M1395 | TX |
NPI | 1063493617 |
---|---|
Provider Name | Christine Vidouria |
First Address | San Antonio, TX 78229-3919 |
Second Address | San Antonio, TX 78229-3919 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/11/2005 |
Last Update Date | 26/10/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
188093202 | (05) | TX |
I43789 | (02) | TX |
M1395 | STATE MEDICAL LICENSE (01) | TX |