Provider Demographics
NPI:1558371070
Name:LANTRY, BRUCE R (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:R
Last Name:LANTRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10325 LOST BLUFF
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-3537
Mailing Address - Country:US
Mailing Address - Phone:210-520-5595
Mailing Address - Fax:210-692-0359
Practice Address - Street 1:2020 BABCOCK RD
Practice Address - Street 2:SUITE #29
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4443
Practice Address - Country:US
Practice Address - Phone:210-692-0358
Practice Address - Fax:210-692-0359
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK2944208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG48612Medicare UPIN