Provider Demographics
NPI:1730486077
Name:UDOLISA, AZUKA DOREEN-JANE
Entity Type:Individual
Prefix:DR
First Name:AZUKA
Middle Name:DOREEN-JANE
Last Name:UDOLISA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 PARK TEN BLVD STE 200S
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-4293
Mailing Address - Country:US
Mailing Address - Phone:210-261-1060
Mailing Address - Fax:210-261-1821
Practice Address - Street 1:601 N FRIO ST BLDG 1
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3011
Practice Address - Country:US
Practice Address - Phone:210-261-3750
Practice Address - Fax:210-444-1474
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXS78122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program