Provider Demographics
NPI:1881663557
Name:WIESENTHAL, ALEXIS A (MD)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:A
Last Name:WIESENTHAL
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 1:7950 FLOYD CURL DR
Mailing Address - Street 2:SUITE 1010
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3919
Mailing Address - Country:US
Mailing Address - Phone:210-614-1010
Mailing Address - Fax:210-949-1010
Practice Address - Street 1:7950 FLOYD CURL DR
Practice Address - Street 2:SUITE 1010
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3919
Practice Address - Country:US
Practice Address - Phone:210-614-1010
Practice Address - Fax:210-949-1010
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36165207R00000X
CAA103118207R00000X
TXN1219207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX219490401Medicaid
TX219490401Medicaid