Provider Demographics
NPI:1831109909
Name:ELIZONDO, BEN JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:JOSEPH
Last Name:ELIZONDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 GALLERY CIRCLE
Mailing Address - Street 2:SUITE 127
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258
Mailing Address - Country:US
Mailing Address - Phone:210-267-1197
Mailing Address - Fax:210-802-4926
Practice Address - Street 1:109 GALLERY CIRCLE
Practice Address - Street 2:SUITE 127
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258
Practice Address - Country:US
Practice Address - Phone:210-267-1197
Practice Address - Fax:210-802-4926
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ77762080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG23827Medicare UPIN
00203GMedicare ID - Type Unspecified