Provider Demographics
NPI:1326117425
Name:MILBOURN, JOHN MARK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:MILBOURN
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 1:325 KENNEDY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-5249
Mailing Address - Country:US
Mailing Address - Phone:830-643-6162
Mailing Address - Fax:
Practice Address - Street 1:600 N UNION AVE
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-4194
Practice Address - Country:US
Practice Address - Phone:830-643-6162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ75852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C9063Medicare ID - Type Unspecified
TXG24164Medicare UPIN