Provider Demographics
NPI:1770530974
Name:SAMANO, ITALO AUGUSTO (PHD)
Entity type:Individual
Prefix:MR
First Name:ITALO
Middle Name:AUGUSTO
Last Name:SAMANO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3019 FALL WAY DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-3233
Mailing Address - Country:US
Mailing Address - Phone:210-495-6346
Mailing Address - Fax:
Practice Address - Street 1:4242 MEDICAL DR
Practice Address - Street 2:SUITE 6300
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5640
Practice Address - Country:US
Practice Address - Phone:210-614-8400
Practice Address - Fax:210-614-8165
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23724103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151188301OtherMEDICAID GROUP
TX128813606Medicaid
TX01-0624198OtherTAX ID # FOR GROUP
TX151188301OtherMEDICAID GROUP
TX128813606Medicaid