Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | H2253 | TX |
NPI | 1003837758 |
---|---|
Provider Name | Javier C Bocanegra |
First Address | San Antonio, TX 78228 |
Second Address | San Antonio, TX 78228 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/07/2006 |
Last Update Date | 06/07/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
121539404 | (05) | TX |
E03347 | (02) |