Provider Demographics
NPI:1932479573
Name:EWESUEDO, REGINALD (MD)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:EWESUEDO
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:PO BOX 40116
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-1116
Mailing Address - Country:US
Mailing Address - Phone:210-625-1171
Mailing Address - Fax:
Practice Address - Street 1:7800 IH 10 W
Practice Address - Street 2:SUITE 612
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-4700
Practice Address - Country:US
Practice Address - Phone:210-625-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-11
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN20692080P0207X, 208U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208U00000XAllopathic & Osteopathic PhysiciansClinical Pharmacology
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH20466Medicare UPIN