Provider Demographics
NPI:1184694457
Name:BRISENO, CHARLES G SR (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:G
Last Name:BRISENO
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CHARLES
Other - Middle Name:G
Other - Last Name:BRISENO
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:SUITE 703 414 NAVARRO
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78205-2515
Mailing Address - Country:US
Mailing Address - Phone:210-224-4811
Mailing Address - Fax:210-224-8678
Practice Address - Street 1:SUITE 703 414 NAVARRO
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-2515
Practice Address - Country:US
Practice Address - Phone:210-224-4811
Practice Address - Fax:210-224-8678
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD3167207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
834022OtherBCBS
TXB21508Medicare UPIN
TX834022Medicare PIN