Provider Demographics
NPI:1720195704
Name:KOEBER, BONNY C (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNY
Middle Name:C
Last Name:KOEBER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BONNY
Other - Middle Name:CARTER
Other - Last Name:GILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4502 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4402
Mailing Address - Country:US
Mailing Address - Phone:210-567-4500
Mailing Address - Fax:210-567-0083
Practice Address - Street 1:4502 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4402
Practice Address - Country:US
Practice Address - Phone:210-567-4500
Practice Address - Fax:210-567-0083
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3862207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129578408Medicaid
TX129578408Medicaid