Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213EP1101X | Primary Podiatric Medicine | 633 | TX |
N | 2081S0010X | Sports Medicine | 633 | TX |
N | 213ES0000X | Sports Medicine | 633 | TX |
NPI | 1568532950 |
---|---|
Provider Name | Dr. Lawrence Allen Czelusta I |
First Address | San Antonio, TX 78266-2858 |
Second Address | San Antonio, TX 78217-5509 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/11/2006 |
Last Update Date | 14/03/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00FF35 | BCBS PROVIDER NUMBER (01) | TX |
333800YX2Y | PTAN (01) | TX |
T12879 | (02) | TX |