Provider Demographics
NPI:1467803064
Name:PANICCO, PRESTON JOHN (DPM)
Entity Type:Individual
Prefix:DR
First Name:PRESTON
Middle Name:JOHN
Last Name:PANICCO
Suffix:
Gender:M
Credentials:DPM
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8042 WURZBACH RD STE 450
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3808
Mailing Address - Country:US
Mailing Address - Phone:210-761-2185
Mailing Address - Fax:702-734-4900
Practice Address - Street 1:14615 SAN PEDRO AVE STE 160
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-4364
Practice Address - Country:US
Practice Address - Phone:210-899-1026
Practice Address - Fax:210-490-1878
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH59.000613213ES0103X
NV2045213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV11467803064Medicaid