Provider Demographics
NPI:1568688752
Name:DECO DISTRICT DOCTORS OFFICE LLC
Entity Type:Organization
Organization Name:DECO DISTRICT DOCTORS OFFICE LLC
Other - Org Name:BROMLEY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROMLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-732-5100
Mailing Address - Street 1:3202 SAN PEDRO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2247
Mailing Address - Country:US
Mailing Address - Phone:210-732-5100
Mailing Address - Fax:210-732-5108
Practice Address - Street 1:3202 SAN PEDRO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-2247
Practice Address - Country:US
Practice Address - Phone:210-732-5100
Practice Address - Fax:210-732-5108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0069KDOtherBLUE CROSS GROUP
TX00702PMedicare PIN