Provider Demographics
NPI:1881660454
Name:DEGAETANO, MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:DEGAETANO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16620 N US HIGHWAY 281 STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2679
Mailing Address - Country:US
Mailing Address - Phone:210-614-1231
Mailing Address - Fax:210-499-0811
Practice Address - Street 1:5620 LONE STAR PKWY # 2
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-2202
Practice Address - Country:US
Practice Address - Phone:210-403-7978
Practice Address - Fax:210-680-0206
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1624207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176166001Medicaid
TXI39264Medicare UPIN
TX8D8422Medicare ID - Type Unspecified