Provider Demographics
NPI:1588848790
Name:EDRIS, ROBERT W (MED)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:W
Last Name:EDRIS
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6609 BLANCO ROAD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-6131
Mailing Address - Country:US
Mailing Address - Phone:210-342-2299
Mailing Address - Fax:210-342-5499
Practice Address - Street 1:201 S IH 35 STE B
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-4876
Practice Address - Country:US
Practice Address - Phone:830-609-3438
Practice Address - Fax:830-609-3438
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51259237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K5237OtherMEDICARE INDIVIDUAL PTAN
TX1994675-01Medicaid