Provider Demographics
NPI:1912946427
Name:SOUTH SAN ANTONIO MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:SOUTH SAN ANTONIO MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-924-7158
Mailing Address - Street 1:11765 WEST AVEUNE
Mailing Address - Street 2:PMB 192
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216
Mailing Address - Country:US
Mailing Address - Phone:210-924-7158
Mailing Address - Fax:210-924-4642
Practice Address - Street 1:2207 S ZARZAMORA ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-8005
Practice Address - Country:US
Practice Address - Phone:210-223-3863
Practice Address - Fax:210-224-6305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5950207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00404XMedicare ID - Type UnspecifiedTEXAS MEDICARE