Provider Demographics
NPI:1588804637
Name:WALTER W. ROOT, M.D.P.A
Entity Type:Organization
Organization Name:WALTER W. ROOT, M.D.P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:FOUNTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-692-0224
Mailing Address - Street 1:4242 MEDICAL DR
Mailing Address - Street 2:SUITE 6300
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-5640
Mailing Address - Country:US
Mailing Address - Phone:210-614-8400
Mailing Address - Fax:210-614-8165
Practice Address - Street 1:4242 MEDICAL DR
Practice Address - Street 2:SUITE 6300
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5640
Practice Address - Country:US
Practice Address - Phone:210-614-8400
Practice Address - Fax:210-614-8165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6366174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid
TXPENDINGMedicare PIN
TXPENDINGMedicare UPIN