Provider Demographics
NPI:1154305365
Name:CHRISTOPHERSON, CHAD R (MD)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:R
Last Name:CHRISTOPHERSON
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 1:311 CAMDEN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-2012
Mailing Address - Country:US
Mailing Address - Phone:210-281-9800
Mailing Address - Fax:210-281-1001
Practice Address - Street 1:311 CAMDEN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-2012
Practice Address - Country:US
Practice Address - Phone:210-281-9800
Practice Address - Fax:210-281-1001
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7913207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201587701Medicaid
TX613479Medicare PIN
TX201587701Medicaid