Provider Demographics
NPI:1003824335
Name:DESILVA, THUSHAN N (MD)
Entity Type:Individual
Prefix:
First Name:THUSHAN
Middle Name:N
Last Name:DESILVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12446 WEST AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-2517
Mailing Address - Country:US
Mailing Address - Phone:210-525-1668
Mailing Address - Fax:210-525-1669
Practice Address - Street 1:120 OLD SAN ANTONIO RD
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-3413
Practice Address - Country:US
Practice Address - Phone:830-331-4150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9763207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH12499Medicare UPIN
81152JMedicare ID - Type Unspecified