Provider Demographics
NPI:1265801492
Name:BULVERDE FAMILY MEDICINE PA
Entity type:Organization
Organization Name:BULVERDE FAMILY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:D
Authorized Official - Last Name:ETHRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-980-1805
Mailing Address - Street 1:805 KELLY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BULVERDE
Mailing Address - State:TX
Mailing Address - Zip Code:78163-3035
Mailing Address - Country:US
Mailing Address - Phone:830-980-1805
Mailing Address - Fax:830-438-5662
Practice Address - Street 1:805 KELLY CREEK RD
Practice Address - Street 2:
Practice Address - City:BULVERDE
Practice Address - State:TX
Practice Address - Zip Code:78163-3035
Practice Address - Country:US
Practice Address - Phone:830-980-1805
Practice Address - Fax:830-438-5662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-17
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6877207Q00000X, 305R00000X
207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX386676601Medicaid
TXL6877OtherMEDICAL LICENSE