Provider Demographics
NPI:1669721338
Name:VYDRZAL, WILLIAM STANLEY (CP)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:STANLEY
Last Name:VYDRZAL
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 NORTH MAIN, SECOND FLOOR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78205-1204
Mailing Address - Country:US
Mailing Address - Phone:210-237-4358
Mailing Address - Fax:
Practice Address - Street 1:610 N. MAIN AVENUE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-1204
Practice Address - Country:US
Practice Address - Phone:210-225-6508
Practice Address - Fax:210-225-1486
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1252224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1252OtherTEXAS PROSTHETIC LICENSE