Provider Demographics
NPI:1629391842
Name:DIABETES AND GLANDULAR DISEASE CLINIC CERTIFIED DIABETES EDUCATION CEN
Entity Type:Organization
Organization Name:DIABETES AND GLANDULAR DISEASE CLINIC CERTIFIED DIABETES EDUCATION CEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINIC OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:210-615-5541
Mailing Address - Street 1:5107 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4801
Mailing Address - Country:US
Mailing Address - Phone:210-614-8612
Mailing Address - Fax:210-615-1666
Practice Address - Street 1:5107 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4801
Practice Address - Country:US
Practice Address - Phone:210-614-8612
Practice Address - Fax:210-615-1666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-02
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121762202Medicaid
TX121762202Medicaid