Provider Demographics
NPI:1255315693
Name:ROMAN, MICHAEL A (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:ROMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4242 MEDICAL DR STE 7100
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-5397
Mailing Address - Country:US
Mailing Address - Phone:210-342-1906
Mailing Address - Fax:210-570-8203
Practice Address - Street 1:4242 MEDICAL DR
Practice Address - Street 2:#6150
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5640
Practice Address - Country:US
Practice Address - Phone:210-342-1906
Practice Address - Fax:210-949-1909
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24435103T00000X, 103TC0700X, 103G00000X
TX30235103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX285657OtherVALUE OPTIONS
TX243539000OtherMAGELLAN BEHAVIORAL HEALT
TX110626202Medicaid
TX285657OtherVALUE OPTIONS