Provider Demographics
NPI:1497240295
Name:IPPOLITI DI MAURO, MICHELINA ROSA (MD)
Entity Type:Individual
Prefix:MISS
First Name:MICHELINA
Middle Name:ROSA
Last Name:IPPOLITI DI MAURO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:903 W MARTIN ST # MS 52-2
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-0903
Mailing Address - Country:US
Mailing Address - Phone:210-358-5909
Mailing Address - Fax:210-358-5940
Practice Address - Street 1:2121 SW 36TH ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78237-3360
Practice Address - Country:US
Practice Address - Phone:210-358-5100
Practice Address - Fax:210-358-5157
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
TXS8717207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program