Provider Demographics
NPI:1790764983
Name:JENDRZEY, DIANE (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:JENDRZEY
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 1:333 N SANTA ROSA ST
Mailing Address - Street 2:STE D4023
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3108
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-2609
Practice Address - Street 1:8366 N LOOP 1604 W
Practice Address - Street 2:STE 105
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-3533
Practice Address - Country:US
Practice Address - Phone:210-680-6000
Practice Address - Fax:210-680-9153
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8199208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87460GOtherBCBS
TX136388910Medicaid
TX136388904Medicaid
TX136388908Medicaid
TX1790764983OtherNPI
87460GMedicare PIN
TXB23752Medicare UPIN