Provider Demographics
NPI:1922199199
Name:LEROUX, EDMOND JOSEPH (M D)
Entity Type:Individual
Prefix:
First Name:EDMOND
Middle Name:JOSEPH
Last Name:LEROUX
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1933 NE LOOP 410
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5320
Mailing Address - Country:US
Mailing Address - Phone:210-804-6001
Mailing Address - Fax:
Practice Address - Street 1:1933 NE LOOP 410
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217
Practice Address - Country:US
Practice Address - Phone:210-804-6000
Practice Address - Fax:210-804-6069
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX43825207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114240801Medicaid
TX85V352OtherBCBS
TX110078952Medicare PIN
TX114240801Medicaid
TX85V352OtherBCBS