Provider Demographics
NPI:1528183001
Name:BOURGEOIS, JONATHAN W (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:W
Last Name:BOURGEOIS
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 1:1919 ROGERS RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-4614
Mailing Address - Country:US
Mailing Address - Phone:210-541-0700
Mailing Address - Fax:210-541-6868
Practice Address - Street 1:1919 ROGERS RD
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251
Practice Address - Country:US
Practice Address - Phone:210-541-0700
Practice Address - Fax:210-541-6868
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR6346207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3861148Medicaid