Provider Demographics
NPI:1790944577
Name:MARSHALL PACKARD
Entity Type:Organization
Organization Name:MARSHALL PACKARD
Other - Org Name:MARSHALL PACKARD, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:B
Authorized Official - Last Name:PACKARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-951-9501
Mailing Address - Street 1:11844 BANDERA RD
Mailing Address - Street 2:#452
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4132
Mailing Address - Country:US
Mailing Address - Phone:210-951-9501
Mailing Address - Fax:210-571-1697
Practice Address - Street 1:414 NAVARRO ST
Practice Address - Street 2:SUITE 502
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-2516
Practice Address - Country:US
Practice Address - Phone:210-223-2145
Practice Address - Fax:210-615-7619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1419207R00000X, 2083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH51557Medicare PIN