Provider Demographics
NPI:1679671994
Name:DIGESTIVE DISEASES CENTER OF SOUTH TEXAS, PLLC
Entity Type:Organization
Organization Name:DIGESTIVE DISEASES CENTER OF SOUTH TEXAS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-253-3422
Mailing Address - Street 1:PO BOX 17650
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-0650
Mailing Address - Country:US
Mailing Address - Phone:210-253-3422
Mailing Address - Fax:210-227-9833
Practice Address - Street 1:621 CAMDEN ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1612
Practice Address - Country:US
Practice Address - Phone:210-253-3422
Practice Address - Fax:210-227-9833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX085153702Medicaid
TX00T16ZOtherBC/BS
TX00T16ZMedicare PIN
TX00T16ZOtherBC/BS