Provider Demographics
NPI:1801890504
Name:SAN ANTONIO ORTHOTICS
Entity type:Organization
Organization Name:SAN ANTONIO ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOTIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DOMINGO
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LO,BOCO, CO
Authorized Official - Phone:210-496-9940
Mailing Address - Street 1:18585 SIGMA RD
Mailing Address - Street 2:STE 104
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4204
Mailing Address - Country:US
Mailing Address - Phone:210-496-9940
Mailing Address - Fax:210-403-0571
Practice Address - Street 1:18585 SIGMA RD
Practice Address - Street 2:STE 104
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4204
Practice Address - Country:US
Practice Address - Phone:210-496-9940
Practice Address - Fax:210-403-0571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101162335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1230140002Medicare ID - Type Unspecified