Provider Demographics
NPI:1215613047
Name:ELIZONDO, JORGE ALEJANDRO
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:ALEJANDRO
Last Name:ELIZONDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 VALLEY HI DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78227-4602
Mailing Address - Country:US
Mailing Address - Phone:210-673-1760
Mailing Address - Fax:866-592-4944
Practice Address - Street 1:302 VALLEY HI DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78227-4602
Practice Address - Country:US
Practice Address - Phone:210-673-1760
Practice Address - Fax:866-592-4944
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX43077183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist