Provider Demographics
NPI:1235160250
Name:SOUTH TEXAS SPORTS MEDICINE INC
Entity Type:Organization
Organization Name:SOUTH TEXAS SPORTS MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:ZYLKS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:361-728-4288
Mailing Address - Street 1:5530 LIPES BLVD
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-5511
Mailing Address - Country:US
Mailing Address - Phone:361-993-9494
Mailing Address - Fax:361-993-4477
Practice Address - Street 1:203 CEDAR DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374-2900
Practice Address - Country:US
Practice Address - Phone:361-643-3993
Practice Address - Fax:361-643-4477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX604380001261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
177212100OtherDEPARTMENT OF LABOR
TX094468802Medicaid
TX0019BGOtherBLUE CROSS BLUE SHIELD
TX094468801Medicaid
TX094468801Medicaid