Provider Demographics
NPI:1427227602
Name:QUEZADA, GERARDO (MD)
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:
Last Name:QUEZADA
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 1:8109 FREDERICKSBURG RD
Mailing Address - Street 2:PHYSICIAN PRACTICE SERVICES
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3311
Mailing Address - Country:US
Mailing Address - Phone:210-575-6240
Mailing Address - Fax:210-575-6280
Practice Address - Street 1:4410 MEDICAL DR
Practice Address - Street 2:SUITE 540
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3749
Practice Address - Country:US
Practice Address - Phone:210-575-6240
Practice Address - Fax:210-575-6280
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7544207RH0000X, 208000000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191616506OtherCSHCN
TX8F10114OtherMEDICARE
TX191616505Medicaid
8BX396OtherBCBS TX
TX8F10114OtherMEDICARE