Provider Demographics
NPI:1629186697
Name:IRVIN, LINDSAY R (MD)
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:R
Last Name:IRVIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 E BASSE RD STE 108
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-8329
Mailing Address - Country:US
Mailing Address - Phone:210-804-0485
Mailing Address - Fax:
Practice Address - Street 1:555 E BASSE RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-8353
Practice Address - Country:US
Practice Address - Phone:210-930-8400
Practice Address - Fax:210-930-8402
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9890208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG65171Medicare UPIN
TX8A5231Medicare ID - Type Unspecified